Claims Officer at Eden Solutions and Resources

Job Description

• The Claims Officer (HMO) is responsible for processing and adjudicating health insurance claims in a timely and accurate manner.
• This will include verifying coverage, determining eligibility, and processing payments to providers. You will also work to resolve member complaints and investigate potential fraud.

What should you do to be considered successful?

• Process and adjudicate health insurance claims in a timely and accurate manner
• Verify coverage and determine eligibility for members
• Process payments to providers
• Resolve member complaints and investigate potential fraud
• Maintain accurate and up-to-date records of all claims
• Work with other departments to ensure that claims are processed and adjudicated in accordance with company policies and procedures
• Stay up-to-date on the latest changes to healthcare laws and regulations
• Provide excellent customer service to members and providers
• Process payments to seller partner pharmacies, telemedicine and laboratories
• Set up proper claims processing procedures - keeping accurate records of HMO orders, supplies by partner providers, confirm receipts in writing by HMO enrollees and proper submission of claims to HMOs
• Keep proper records of outstanding claims at the providers and HMOs and ensure proper reconciliation
• Ensure on-time payment by the HMOs

What should you have done in your career?

• Bachelor's Degree in a related field, such as Business Administration, Healthcare Administration, or Public Health
• 2+ years of experience in claims processing or a related field
• Must be working in same role at another Pharmacy Benefits Company
• Strong knowledge of health insurance plans and benefits
• Excellent analytical and problem-solving skills
• Ability to work independently and as part of a team
• Excellent communication and interpersonal skills
• Experience with HMO claims processing systems
• Experience with healthcare fraud investigation
• Experience with customer service.

How important are you to the bottom line?

• You play a pivotal role in managing and processing claims efficiently. Your accuracy and effectiveness directly impact customer satisfaction, financial stability, and compliance with healthcare regulations, essential to the overall success of the organization.

Biggest problem solving duty in this role:

• To effectively navigate and resolve complex claims issues, ensuring accurate and timely processing, minimizing disputes, and maintaining compliance with healthcare regulations to uphold customer trust and financial integrity for the organization.