Claims Processor

Tufts Health Plan – Watertown, MA

Process core claims as assigned by supervisor:

  • Examine claim to correct and/or update data so claim can properly adjudicate
  • Ensure claim payment is updated to correctly reflect Tufts Health Plan's status as primary or secondary payer through the appropriate coordination of benefits
  • Determine member's eligibility if in question.
  • Check to determine if services rendered on the claim are allowable under the members benefit plan and/or the proper authorization, referrals and pre-registrations were obtained as required by the plan.
  • Communicate with partner departments (verbally and/or written) to obtain missing information to properly adjudicate claims, such as provider numbers, authorizations and referrals.
  • Manually calculate and/or apply pricing to each claim when necessary
  • Monitor pending claims daily and ensure claims are released timely for adjudication
  • Quality & Production:

  • Achieve individual standards for quality and production as assigned by supervisor
  • Contribute to team and departmental standards for quality and production
  • Participate in identifying opportunities for overall process improvements
  • Other:

  • Participate in initiatives or provide back up support to other areas of department as requested
  • Participate in staff & individual meetings and training sessions as required
  • Comply with all department and company guidelines and policies
  • EDUCATION: Associates degree or equivalent business experience in a claims/customer service healthcare environment preferred.

    EXPERIENCE: 12-18 months experience in a Tufts Health Plan claims /customer service position or similar claims processing experience required

    SKILL REQUIREMENTS: Experience with Tufts Health Plan's internal applications, such as TAHPMaster, Macess, Infolink, (CMT) preferred. Understanding of managed care concepts and a strong understanding of CPT, ICD-9 (ICD-10), HCPCS coding guidelines and CMS1500 & UB04 billing forms preferred. Position requires basic problem solving and analytical skills with the ability to multi-task. Must be able to work independently and as a part of a team. Ability to effectively communicate to partner departments. Working knowledge of Microsoft Office applications and internet navigation is preferred.

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