POSITION SUMMARY/RESPONSIBILITIES
Analyze complex problems pertaining to claim payments, eligibility, other insurance, transplants, and system issues that are beyond the scope of claim examiners and senior claim examiners that affect claims payment. Act as a consultant to claims staff in complex claim issue resolution. Work cooperatively with Configuration in testing of contracts used in business operations and reporting to assure auto adjudication. Perform in accordance with company standards and policies. Promote harmonious relationships within own department, with other departments, and within CFHP. Operate under limited supervision.
EDUCATION/EXPERIENCE
High school diploma or GED equivalent is required.
Five years HMO/PPO claims experience is required.
Amisys claims processing system experience is preferred.
Knowledgeable of all benefit programs offered by the CFHP, Medicaid, HMO, PPO, ASO.