The Claims Specialist ensures the accurate entry of inpatient and outpatient claims per the data entry guidelines, and ensures the timely processing of claims per the adjudication rules for accurate payment or denial. The incumbent is also responsible for the accurate use of referral guidelines and benefit plans. Other duties include: filing; assisting outside providers, members, and staff regarding claims related questions or issues; and assisting internal staff on complex claims related questions and problems. The Claims Specialist performs under the general direction, guidance, and supervision of the Claims Supervisor.
The incumbent knows and abides by all Group Health Cooperative of South Central Wisconsin (GHC-SCW) organizational and departmental policies, sets personal standards and strives for high quality work in completing assignments, performs job duties in a timely manner, and represents the organization in a positive manner. The incumbent understands our Mission , Vision and Common Values (stated below) and is committed to promote these values in behavior and attitude.
Our Mission Statement: We partner with members and the communities we serve to maximize health and well-being.
Our Vision: As a local, not-for-profit, member-owned Cooperative, we are the most trusted resource for lifelong health and well-being in the communities we serve.
- We are a not-for-profit Cooperative
- We are member-centered
- We are equitable and inclusive
- We are quality-driven
- We are innovative
- We are community involved
Five Strategic Pillars:
- Exceptional Quality and Service – We seek excellence by working towards the elements of the quadruple aim we strive to be the best we do in all that we do.
- Meaningful Employee Engagement – We create a culture where employees are involved, enthusiastic and committed to delivering on the GHC-SCW Mission, Vision and Values.
- Continuous Improvement – We actively identify opportunities and initiate change that creates value for the Cooperative and those we serve.
- Financial Strength - We ensure the Cooperative’s long-term viability by reinvesting earnings generated by controlling health care costs and consistently growing revenue.
- Impact - We advance health and well-being by nurturing connections with our member-owners and the communities we serve.
GHC-SCW is committed to fostering a caring and compassionate environment while ensuring that individual differences are valued. GHC-SCW is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. It is essential that all employees, members, and patients feel secure and welcome, that the opinions and contributions of all individuals are respected and that all voices are heard.
Healthcare is a human right.
In treating all people with dignity and respect.
There is strength in diversity.
Equity celebrates our humanity.
We are better together.
JOB SPECIFIC QUALIFICATIONS
- High school graduate or equivalent required.
- One (1) to two (2) years administrative experience in an insurance, healthcare, financial or relevant environment. Previous experience in claims resolution /processing or closely related work in an insurance or healthcare environment is highly desirable.
- Knowledge of or ability to learn and accurately apply claims processing techniques, procedures and practices in a timely manner required.
- Ability to develop and maintain a working knowledge of claims adjudication rules, computer functions, usual and customary costs, discounts, rates, capitated payment arrangements, contract deadlines, provider changes and benefit plans required.
- Knowledge of medical terminology preferred.
- Knowledge or CPT -4 and ICD -9 coding is desirable.
- Knowledge of and ability to use computers including billing system software, database, word processing, email, and calendar programs. Experience with EPIC systems is desirable but not required.
- Good verbal and written communication skills required.
- Good organizational skills required. Must be detail oriented and work with a high degree of accuracy.
- Good customer services skills required, including the ability to build and maintain effective working relationships with internal and external customers.
- Ability to maintain patient confidentiality required. Knowledge of or ability to learn HIPAA requirements.
- Ability to work independently with general supervision required.
- Ability to type accurately required.
- Ability to use a 10-key calculator accurately required.
- Ability to sit and stand intermittently required.
- Ability to use a keyboard extensively required
- Pay Type Hourly
- Administration - 1265 John Q. Hammons Drive, 1265 John Q. Hammons Dr. , Madison, Wisconsin, United States of America