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City/State
Doral, FLOverview
Work Shift
First (Days) (United States of America)AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Claims Adjuster in Miami and/or Gainesville, Florida. This is a hybrid position, 2 days in office and 3 days remote.
Scope of position:The Claims Adjuster is responsible for performing centralized appeal processing functions for AvMed physicians, facilities, and ancillary providers. Identify claims problems and propose solutions.
Essential Job Functions:
- Reviews and makes administrative determination on claim reviews received from providers and other sources.
- Adjust claims resulting from reviews and administrative decisions.
- Interpret policy and procedures to properly adjudicate and review all types of claims. Conduct appropriate research and system inquiries to obtain claim-related information. Perform special projects related to claims review problems. Adjust claims as needed, based on appropriate information.
- Identify and communicate system, provider, and other adjudication problems to improve first time claim processing accuracy.
- Identify providers needing claims experience reviews.
- Understand and apply HIPAA compliance rules when releasing Protected Health Information.
- Interact with other departments to resolve member and provider issues.
- Complies with company policies and procedures, which includes dress code, punctuality as they relate to work time, lunch, and break periods.
- Performs additional duties and responsibilities as assigned by management.
Minimum Requirements:
- Associates required
- Bachelor's in business or related field preferred
- 3-5 years of experience in a complex managed care environment with multiple products and entities, with an emphasis in claims, pricing and/or benefits within healthcare. Previous audit or system configuration experience preferred
Preferred Requirements:
- Strong verbal and written communication skills
- Strong analytical and interpretative skills
- Excellent organizational skills
- Effective problem-solving skills and ability to handle simple and complex tasks
- Detail-oriented skills to adapt to various workflows, multiple tasks, deadlines and changing priorities.
- Medical Coding including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-10) and Diagnosis-related Group (DRG) Codes
- HRP, MACESS, or Similar Software Systems
- Microsoft Office Suite (Word, Excel, Access)
Our Benefits:
As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:
- Medical, Dental, and Vision Insurance
- Paid Annual Leave, Sick Leave
- Flexible Spending Accounts
- Retirement funds with matching contribution
- Supplemental insurance policies, including legal, Life Insurance and AD&D among others
- Work Perks program including discounted movie and theme park tickets among other great deals
- Opportunities for further advancement within our organization
Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits - Sentara (sentaracareers.com)
Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth!
Note: Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.
Keywords: Talroo-Health Plan, Claims, Auditing, QNXT
Job Summary
Responsible for all areas of customer service as it pertains to the acquisition and/ or retention of members for Sentara Health Plan, Inc. This includes functions associated with the administration of all group information: processing of claims, interaction with members, providers and employers. Special reports and projects to include: initial review and analysis, recommendations, SBAR if assigned, Research Team monthly/quarterly reports if assigned, provider site visits/ conference calls if assigned, and new technology testing as assigned.CPC certification OR Related Medical Certification OR Associates Degree (or higher) required
Qualifications:
HS - High School Grad or Equivalent (Required)Certified Professional Coder (CPC) - Certification - American Academy of Professional Coders (AAPC)Administrative, Customer Service, Health Plan Claims DisbursmntsSkills
Microsoft Excel, Microsoft Word, Project Management, Technology/Computer, Typing Speed 30+ WPM, WritingSentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.
In support of our mission "to improve health every day," this is a tobacco-free environment.