Medical Claims Adjuster

As a Medical Claims Adjuster at PEHP Health & Benefits, your primary responsibilities include receiving and entering medical claims for payment, reviewing claims for accuracy, verifying coverage and eligibility, and adjudicating both routine and complex claims according to established policies. Additionally, you'll be processing coordination of benefits and maintaining strict confidentiality while performing other related administrative duties.

To qualify for the Medical Claims Adjuster position at PEHP Health & Benefits, you should have a high school diploma and at least one year of relevant work experience. While specific experience in claims processing is preferred, an equivalent combination of education and experience may be acceptable. Knowledge of medical coding, the intricacies of various claims, and office management systems are also important for success in this role.

Essential skills for a Medical Claims Adjuster at PEHP Health & Benefits include excellent communication abilities—both verbal and written—strong analytical skills for resolving claims management issues, and meticulous attention to detail. Familiarity with medical terminology, claims processes, and the ability to handle stress while multitasking will greatly contribute to your success in this position.

Yes! PEHP Health & Benefits offers an excellent work-life balance, allowing Medical Claims Adjusters to work remotely for 9 out of every 10 workdays. This flexibility is part of our commitment to creating a supportive and productive working environment for all employees. You'll be able to contribute effectively while also enjoying the benefits of remote work.

The work environment for Medical Claims Adjusters at PEHP Health & Benefits is typically an office setting with appropriate climate controls. While the physical tasks involved do not generally require muscular strain, some activities related to walking, standing, sitting, and focused dexterity are required. Overall, it is a supportive atmosphere where you’ll collaborate with your team while also having opportunities for independent work.

When addressing this question, share specific examples of your previous roles where you processed medical claims. Highlight your familiarity with various types of claims, any software you've used, and the attention to detail you maintain throughout the process.

Explain your methods for maintaining accuracy, such as using checklists, verifying information at various stages, and how you prioritize tasks to minimize mistakes. Mention the importance of adhering to established guidelines and the impact of accuracy on customer satisfaction.

Discuss your organizational skills, perhaps mentioning tools you use for task management. Emphasize your ability to prioritize claims based on urgency and complexity and how effective communication within your team helps manage workload.

Illustrate your conflict resolution skills by providing an example of a difficult claim or situation. Discuss how you stay calm, gather all necessary information, listen to concerns, and work collaboratively towards a resolution.

Showcase your understanding of coding systems like CPT, ICD-10-CM, and HCPCs. You might want to discuss how you've previously applied this knowledge to ensure proper claims processing or resolve discrepancies.

Express your alignment with PEHP’s mission of providing quality insurance to public employees. You can mention your admiration for their balance of competitive pay and work-life balance, which shows your awareness of the company culture.

Indicate the resources you use, such as industry journals, networking with professionals, and attending workshops. Highlight your commitment to lifelong learning, which is essential in a continually evolving healthcare landscape.

Discuss strategies you've used in the past for prioritization, such as assessing deadlines, categorizing claims by complexity, and utilizing time management techniques that help you meet deadlines effectively.

Provide a real-life example where you identified an inefficiency in a claims process and took steps to enhance it. Discuss the methods used and the positive outcomes resulting from these improvements.

Share a few key attributes such as attention to detail, strong communication skills, analytical thinking, and the ability to work under pressure. Explain how these skills contribute to effective claims processing and overall team success.