Medical Senior Adjuster

SUMMARY: The Senior Medical Claims Adjuster is responsible for timely and accurate processing of exception and/or complex medical claims for the Plan's participants, complying with the Plan's written provisions and guidelines, and the Fund's administrative policies and procedures. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. Ability to process various types of Medical claims with emphasis on complex claims, adjustments, Medicare Secondary Payer and Medicaid/Medi-Cal inquiries. Provide support and expertise in reviewing and resolving appeals, customer service inquiries, provider claim inquiries and provider disputes. Manage provider alerts for potential fraud, waste and abuse (FWA). Proactively seeks assistance from the appropriate sources to accurately process claims and resolve claims related issues. Interact effectively with other members of the department, the Fund and the Local offices in person or via email, telephone or other written or verbal. Advise lesser experienced adjusters in the resolution/handling of more complex claims issues and assist with training as needed. Interface and effectively manage participants, providers, vendors and other external clients when required in person or via email, telephone or other written. Maintain current department knowledge of plan documents, summaries of plan provisions and other plan materials. Meet or exceed established department production and quality standards on a weekly, monthly, quarterly and annual basis. Proactively identify opportunities for improvement. Actively participate in system testing when needed. Handle all duties and assignments in a timely manner. Perform other job related duties/special projects as assigned. Abide by organizational and HIPAA guidelines, privacy practices, and confidentiality. Comply with the policies of the Trust Fund, as set forth in the Employee Handbook. Adhere to the company’s attendance policy. QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. EDUCATION and/or EXPERIENCE: High School diploma or GED required. 3-4 years of experience as a Medical Claims Examiner. Knowledge of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS), Medical Terminology. Knowledge with International Classification of Diseases (ICD) ICD-9/ICD-10 codes and guidelines. PPO claims processing experience, including prior experience in WGS processing system preferred. Exceptional Customer service skills' with the ability to build rapport with Plan participants, team members and other employees of the Fund. Able to utilize MS Office (Excel, Word and Outlook) proficiency required. OTHER SKILLS and ABILITIES: Dedication to upholding the company’s mission, vision and values. Ability to utilize plan documents and claims processing guidelines in order to make independent decision on the adjudication of claims. High attention to detail.