Documents Processor II - Claims (Hybrid with On site in Troy, MI) - Health Alliance Plan

General Summary:

To ensure all incoming claims/documents are distributed and routed accurately to the appropriate departments. Utilizing Pega and Facet systems to increase the efficiency of the Claim and Enrollment departments by providing support for the Claims Processors, Enrollment Reps., Adjustment Reps., and COB Analysts. Coordinate and participate in departmental activities to increase efficiency and process layout.

Principal Duties and Responsibilities:

• Open, sort, batch, and distribute incoming mail daily.
• Utilize the scanner to record claim, cob and enrollment documentation according to appropriate inventory type.
• Validate and release the recorded scanned documents into the appropriate database system.
• Process unaccepted reports, Data Direction Incorporated-(DDI) returned mail, sorting and mailing of Explanation of Benefits (EOBs).
• Mail request to provider for additional claim information when pertinent information is missing.
• Maintain accurate files of claims, claims reports and all related documents.
• Navigate through the CRM Pega system to create/close COB, and Claims processing pega cases for the appropriate COB Analyst and Claim Processor to analyze and resolve each case created.
• Navigate through the Facet system to retrieve member or claims missing information.
• Navigate through the Facet system to verify if a claim was previously submitted.
• Navigate through the Facet system to input claim adjustment and appeals information for the appropriate Adjustment Processor to analyze and resolve.
• Record daily production and time including CTO time. Compile bi-weekly reports reflection lost time information.
• Provide back-up for other co-workers in the division.
• Perform other related duties as assigned.