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Luminex Claims Examiner

Company: NTT DATA
Location: Wilsall
Posted on: September 22, 2022

Job Description:

NTT Data seeks a full time, -direct hire -Luminex -Claims Examiner/Plan Builder for our customer in Missoula, MT to work onsite or -REMOTE.** NTT Data is assisting our healthcare client with the recruiting efforts for this position. This is not a position with NTT DATA.**POSITION RESPONSIBILITIES:The Plan Builder is responsible for the creation, maintenance, and improvement of plan benefit set-ups in the software system used to process and pay medical, dental, vision, and disability claims. The incumbent is also responsible for setting up PPO benefits and coordinating the maintenance of PPO providers with the individual(s) maintaining the provider records and back-up maintenance of the IVR system.The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position.ESSENTIAL JOB FUNCTIONS:Essential job functions include the following. Other functions may be assigned as business conditions change.

  • Creates new plan benefit set-ups by reviewing and interpreting the plan document supplied as the plan benefits for the new group.
  • Works with marketing and legal department personnel to determine the system capability of proposed new benefits or plan provisions.
  • Maintains existing plan benefit set-ups based on amendments or new plan documents for existing groups.
  • Creates PPO set-ups based on the plan document for new groups.
  • Maintains PPO plan benefit set-ups based on amendments or new plan documents for existing groups.
  • Creates, maintains and improves PPO plan benefit set-ups.
  • Maintains knowledge of the claims processing software and researches methods of improving the processing of claims utilizing system features.
  • Maintains PPO set-ups in group master files.
  • Creates and maintains PPO repricing logic within the system.
  • Coordinates PPO maintenance and provides assistance with PPO maintenance to the individual(s) maintaining provider records in the system.
  • Investigates problems as represented by claims examiners or auditors; identifies problems and codes corrections within the system.
  • Complies with all privacy and confidentiality laws in the course of business.
  • Supports the IVR Maintenance Specialist by handling back-up responsibilities for the IVR system.
  • Contributes to the daily workflow with regular and punctual attendance.NON-ESSENTIAL JOB FUNCTIONS:
    • Coordinates plan benefit problems with the Plan Building Supervisor and/or the Claims Department Manager.
    • Assists with provider/PPO maintenance.
    • Performs related or other assigned duties as required or directed.PHYSICAL WORKING CONDITIONS:Physical requirements are representative of those that must be met to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Sitting 90% Reaching Some Standing 5% Manual Dexterity High Walking 5% Telephone Yes Kneeling Some Computer Screen High (visual acuity corrected to 20/30) Bending Some Lifting up to 20 lbs.JOB SPECIFICATIONS:To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
      • Minimum Education: High school graduation or GED required. College degree and/or training in medical terminology and health benefits preferred.
      • Completion of a minimum of three HIAA and/or ICA courses. An undergraduate degree will be accepted as a waiver of this requirement to obtain the position, but successful completion of these courses will be required to remain in the position.
      • Minimum Experience: One year of experience in the health insurance industry is required in the absence of an undergraduate degree. Formal training in computer programming or an aptitude for converting plan language into programming language is required.Other Qualifications:
        • Excellent oral and written communication skills required.
        • PC skills, including Windows and Word. Must be able to adapt to software changes as they occur.
        • Thorough understanding of claims processing procedures and requirements.
        • Ability to think creatively to produce solutions to claims processing problems.
        • Ability to create the most efficient method possible for processing claims.
        • Ability to be trained to understand and produce computer programming code in the software system required language.
        • Typing ability of 40 wpm net.
        • Knowledge of medical terminology and basic health insurance concepts.
        • Excellent listening skills.
        • Basic mathematical skills.
        • High level of interpersonal skills to work effectively with others.
        • Ability to organize and recall large amounts of detailed information.
        • Ability to read, analyze and interpret benefit summary plan descriptions, insurance documents and regulations. Ability to convert that understanding into the system required coding necessary to pay benefits.
        • Ability to project a professional image and positive attitude in any work environment.
        • Ability to comply with confidentiality and privacy standards.
        • Ability to be flexible, work under pressure and meet deadlines.
        • Ability to analyze and solve problems with professionalism and patience.
        • Ability to prioritize problems and responsibilities.
        • Ability to operate typical office equipment.
        • Working knowledge of general office procedures.*This is not an NTT DATA position. NTT DATA is helping identify the ultimate candidate to present for this open opportunity with our customer hiring direct for a Luminex Claims Examiner/Plan Builder in Missoula, MT onsite or REMOTE. However, the info below is related to NTT DATA should you want further information about careers within the company.

Keywords: NTT DATA, Billings , Luminex Claims Examiner, Other , Wilsall, Montana

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