Claims Examiner, Commercial / ASO

MVP Health Care is a nationally-recognized, regional not-for-profit health plan committed to having a positive impact on health and wellness of everyone we serve. With MVP, you are assured of quality health care and peace of mind—from a name you know and trust. We care for more than 700,000 members across New York and Vermont, creating healthier communities and continuing our 30-year legacy of quality and integrity.

Using a PC /Microsoft Window environment, adjudicates claims with the aid of the Facets and Macess Systems. Reviews and ensures the accuracy of all provider, member and claim line information for all claims for which the examiner is responsible. Reviews and ensures the accuracy of all changes to claim line information based on information received from other departments and in accord with available benefit information. Is responsible for the timely and accurate adjudication of claims that are suspended to other MVP departments for benefit and/or authorization determination. Meets or exceeds department quality and work management standards for claims adjudication. Successfully completes a course of comprehensive formal training in all areas of benefits determination, system navigation, and MVP policy. Suspends, investigates and resolves claim issues by coordinating with appropriate departments, based on criteria set by those departments. Handles inquiries regarding suspended claims from other departments and identifies trends in suspensions based on these inquiries and other feedback. Reports same to Claims Operations Supervisor. Familiarizes themselves of all benefit changes. Provides ongoing feedback to the senior or Claims Operations Supervisor to insure all appropriate personnel are kept informed. Performs other duties as assigned.

Minimum Education: 2 year college degree or directly related business experience. Minimum Experience: Previous health/dental insurance experience required. Required Skills: Independent Adjusters License is required. (If not certified when hired or transferred into position, must obtain in the next IAC training class.) Strong communication skills Organizational skills and attention to detail; Strong PC skills required, Microsoft Windows experience highly desired Essential: * Attention to Detail - Pays attention to details, checks for correctness. Keeps track of details to ensure work is performed accurately and completely. Focuses well, avoids distractions. * Communication - Provides clear, concise information to others in a variety of formats (verbal, written, electronic, etc.). Listens actively and empathetically to the views of others. Asks the appropriate questions to ensure that all relevant facts are considered before a decision is made or an action is initiated. Helps others consider new perspectives. Delivers critical information to all stakeholders/everyone involved. Seeks to clarify ambiguity. Utilizes communication technology. * Customer Service - Provides prompt and courteous service. Takes the time to uncover the customer's real needs and provides solutions that directly relate to customers' requests. Provides solutions that directly related to customers requests or anticipated needs. Works constantly to provide superior value to the customer, making each interaction a positive one. Shows enthusiasm when interacting with customers. Patiently and calmly tolerates rude customers; apologizes sincerely for inconveniences. * Follows Procedures - Understands and follows prescribed company and department policies and procedures, to assure outcomes meet defined objectives, even when it is inconvenient to do so. Identifies policies and procedures which interfere with productivity and makes recommendations for process improvement. * Information Gathering - Gathers necessary and appropriate information from a variety of sources, to clarify situations and to facilitate effective planning, decision-making, and problem solving. Records, summarizes, and creates representations of data. Probes skillfully to get the facts. Seeks the perspective of all stakeholders involved. Seeks out knowledgeable people to obtain information or clarify a problem. * Interpersonal Skills - Works effectively in a multicultural environment; respects the opinions, perspectives, customs, and individual differences of others. Interacts appropriately and respectfully with supervisors and coworkers. Uses appropriate strategies and solutions for dealing with conflicts and differences. Utilizes emotional intelligence to identify, understand and manage emotions. Demonstrates sensitivity and empathy. Respects diversity.