Sr Tech Claims Spec

External Description: Senior Technical Claims Specialist

GENERAL SUMMARY
Responsible for servicing customers by processing claims and adjustments within a Contact Center team to meet or exceed customer service requirements. Serves as a training resource, mentor, subject matter expert and coach.

ESSENTIAL RESPONSIBILITIES
- Processes routine to complex claims for all physician, facility and specialty areas, including those requiring difficult manual adjudications , stop loss claims, high dollar claims and adjustments, in accordance with company policies and procedures.
- Researches customer information by effectively using the "Essentials" on-line resource library and Customer Service Console to gather documentation needed to process claims and adjustments. Examines information including, but not limited to, authorizations, payments, denials, coordination of benefits, and eligibility. Creates, updates and monitors claims payment training information. Readily assesses and applies information to various situations.
- Investigates, analyzes and resolves outstanding issues to achieve customer satisfaction; uses a systematic approach in solving problems through analysis and evaluation of information and alternate solutions.
- Acts independently and manages own activities with minimal supervision and direction to meet customer needs using sound decision making. Assists other team members; takes ownership for problem resolution.
- Performs peer audits including claims quality reviews.
- Handles difficult customer interactions.
- Tests new benefit plans, contracts, rule banks and operational enhancements.
- Manages work distribution including paper claims, correspondence and work queues. Monitors and adjusts workflow accordingly for load balancing purposes.
- Maintains production and claims quality standard while working on special projects.
- Demonstrates expert knowledge of all products.
- Assesses training needs within the team. Serves as a training resource, mentor and coach to others, particularly new hires. Identifies and shares best practices.
- Continuously seeks avenues for growing professional expertise and actively pursues new learning opportunities, which support the companys goals and objectives.
- Demonstrates, advocates and reinforces a positive team environment, professionalism and the need to present a positive image of the company when interacting with customers.
- May interface with customers via telephone to respond to inquiries and resolve concerns on an as-needed basis
- Performs other duties as required.

JOB SPECIFICATIONS
- High school degree or equivalent.
- 3-4 years claims processing or equivalent experience.
- Demonstrates leadership skills and initiative.
- Excellent planning and organizing skills.
- Skilled at developing teamwork and achieving results; skilled at developing and maintaining effective working relationships.
- Excellent analytical and problem solving skills; able to use good judgement.
- Demonstrates independent decision making skills.
- Excellent verbal and written communication skills.
- Able to locate, analyze and apply information to new and diverse situations.
- Able to effectively handle multiple tasks.
- Demonstrates effective keyboard skills; ability to navigate within a computer/systems-dependent environment without assistance; experience in a windows-based computer environment .
- Able to think on ones feet.
- Able to help others remain calm and controlled in stressful, unexpected situations.
- Able to provide constructive feedback and serve as a training resource, mentor and coach.
- Able to maintain regular and consistent attendance in accordance with company and departmental policies and procedures.

To be considered for employment, please apply directly with Coventry Health Care by going to the "Join Our Team" section at www.cvty.com, create your profile and refer to job requisition #128300.

Please refer to job code 128300 when responding to this ad.

Category:	Accounting/Banking/Finance/Insurance
	> Claims
Location:	Rockville, MD
County:	Montgomery County
ZIP Code:	20847
Pay Rate:	Open
Job Terms:	full time
Company:	Coventry Health Care
Phone:	email only please
Fax:	email only please