SENIOR LIFE CLAIMS ADJUSTER                            MIDWEST                            $50 - 60K

GENERAL:
Under limited supervision, analyzes high dollar and complex claims.  Verifies that the underlying cession(s) is eligible for reinsurance.  Investigates early death and, foreign claims to identify undesirable trends in underwriting and/or claims adjudication practices that indicate a need for discussion with the client. Refers questionable claims to Underwriting, Medical and/or Legal departments when required.  Assists in developing and implementing improvement processes for Claims.  Handles retroceded claims that require manual processes.

 RESPONSIBILITIES:

1.      Analyzes and processes high dollar, complex claims and early death claims;

      verifies that the cession claimed  was properly retroceded to RGA Re and was properly established on RGA Re administration system.  Takes steps to resolve questions that arise from these claims. 

2.      Identifies undesirable underwriting and/or claim adjudication practices that require a need to elevate claim.  Refers questionable claims to underwriting, medical and/or legal departments.  May escalate issue to department vice president or sales department vice presidents. 

3.      Processes retroceded claims: assures that recoverables on large, complex retroceded claims are paid on a timely basis.

4.      Identifies opportunities for investigation or application of “best practices” in client claim     activities.

5.      Verifies daily claim register by scanning the register to ensure accruals are reasonable, required fields are completed and that the register is free of obvious errors.  Authorizes accrual vouchers.

6.      Assists in training of new or junior associates.

7.      Approves and authorizes cash disbursements up to prescribed limits. 

8.      Maintains regular and predictable attendance.

9.      Performs other duties as assigned.

 SPECIFICATIONS:

Education and Experience

Sr. Claims Adjudicator               Pittsburgh                   $hourly

Location:	Pittsburgh
Duties:	Processing healthcare claims, primarily special processing allowances as a result of suspends, administrative adjustments, or processing arrangements that are outside of system functionality from providers, internal departments, the subcontracted vendor responsible for first level processing, or Regulatory Agencies for two Medicaid products and two Medicare products. Completing investigations of benefit levels, eligibility, third party liability, claims histories and provider contract allowances along with analyzing root cause issues that may be impacting payment determinations. Handling all types of claims and applying policies and procedures applicable to exception processing criteria, claims adjustments, COB, manual calculations of certain payments and applying and explaining editing pertinent to the coding software. Provide reimbursement and other claims investigative services to providers who render care to the Medicare and Medical Assistance populations and to internal staff supporting these products.
Qualifications:	Required: High School Diploma or GED. One year experience in auditing and retrospective claims review resulting in adjustment processing. Two years health care claims adjudication experience in addition to one year claims entry experience. Preferred: Three years experience handling high level claims and projects.

 

Contact: Jerry Waering at 800 489 3602 ext. 1 or jerryw@readwaering.com

---