Claims Adjudicator II

Job Overview

The Claims Adjudicator II position will receive, examine, verify and input submitted claim data, determine eligibility status, and review and adjudicate claims within established time frames. This position utilizes multiple systems in order to perform the day-to-day functions of processing medical, disability, vision and dental claims, as well as provider and member driven inquiries.

• Screens claims for completeness of necessary information
• Verifies participant/dependent eligibility
• Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents
• Codes basic information and selects codes to determine payment liability amount
• Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered
• Determines the need for additional information or documentation from participants, employers, providers and other insurance carriers
• Handles the end to end process of Medicare Secondary Payer (MSP) files
• Processes Personal Injury Protection (PIP) claims
• Requests over payment refunds, maintains corresponding files and performs follow-up actions
• Handles verbal and written inquiries received from internal and external customers
• Processes Short Term Disability claims
• Adjudicates claims according to established productivity and quality goals
• Achieves individual established goals in order to meet or exceed departmental metrics

• 3 ~ 5 years of direct experience minimum in a medical claim adjudication environment
• Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
• Experience with eligibility verification, medical coding, coordination of benefits, and subrogation and its related processes
• Experience with medical terminology, ICD
  10 and Current Procedural Technology (CPT) codes
• Fluency (speak and write) in Spanish, preferred

Hourly $20.36 - $24.97.

Monday – Friday, 7.5 hours per day (37.5 hours per week). Fully remote after 1‑week onsite training in Oak Brook, IL. (Travel and Lodging paid by UHH).

Medical, Dental, Vision, Paid Time‑Off (PTO), Paid Holidays, 401(k), Pension, Short‑ & Long‑term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).

Mid‑Senior level

Full‑time

Finance and Sales;
Hospitals and Health Care

#Remote