Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.
SCOPE OF ROLE
The Claims Adjuster uses claims processing guidelines to verify information on submitted claims, review the policy to determine which charges are eligible for reimbursement, researches authorizations, and finalizes claims. They ensure all business rules set by Bright Health Plan are followed and that payments are made according to CMS guidelines, Bright Contract and plan benefit designs.
ROLE RESPONSIBILITIES
The Claim Adjuster job description is intended to point out major responsibilities within the role, but it is not limited to these items.
- Adjudicate and/or readjudicate claims to providers and members accurately.
- Monitor policies and procedures for Bright Health with claims.
- Monitor daily work queues
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- High school diploma required.
- 1-2 years of experience processing commercial facility and professional claims using pricing methodologies (DRG, case rate, per diem, % of billed, fee schedule, etc.) and application of CMS billing guidelines required.
- Intermediate Excel skills for data analysis required.
PROFESSIONAL COMPETENCIES
- Able to create and maintain strong working relationships.
- Complex problem-solving skills.
- Able to manage multiple initiatives and priorities simultaneously.
BEHAVIORAL AND LEADERSHIP NORMS
- Bright Values: Lives the Bright Values. Given the individual role in the organization, creates a culture of positivity within team. Leads by example. Acts with quiet, calm determination. Effectively influences in team setting.
- Communication: Is an effective communicator. Internally, leads 1:1 and small groups of people in meetings. Capable of developing agenda, setting objectives, driving clarity of purpose and delivering the intended results. Can clearly articulate an inspiring goal/objective for each teammate and define success.
- Delivers Results: Is results oriented. Focuses on results, not effort, and is able to efficiently direct time and energy to achieving intended outcome. Takes strategic company initiatives and translates them to implementable processes that drive outcomes. Achieves strong results within their functional area. Focuses on managing against a predetermined set of objectives and creates and follows process.
- Direct Management: May oversees a team of people who interact externally with members/brokers/vendors or who perform highly specialized work. Responsible for training new employees and developing existing employees. Translates corporate goals into actionable individual goals. Delivers thoughtful and constructive feedback to teams. Sets an example for employees. Manages up appropriately and knows how and when to escalate an issue or situation to more senior manager.
- Prioritization: Establishes priorities by looking to predetermined goals in the organization. Is capable of deciphering priorities for self and for others and focuses the group on what must be done today, and who must do what. Is flexible and agile and can quickly reset priorities within team with clarity of purpose.
WORK ENVIRONMENT
- The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
- Travel may be required.
We’re Making Healthcare Right. Together.
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.
