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Encompass Administrator

Trustmark

Encompass Administrator

Riverside, CA
Full Time
Paid
  • Responsibilities

    Welcome to a team of caring and passionate people who work each day to meet the needs of our members and clients. At Health Benefits, you will be part of an organization committed to offering custom self-funded health benefits plans that manage costs – without compromising benefits – by offering innovative solutions, flexibility, transparency and customer support. We are now a subsidiary of Health Care Service Corporation, the largest customer-owned insurance company in the United States and a strategic partner of Health Benefits since 2018, giving us access to increased national scale and support. This is an exciting time to join our team and enhance our culture that emphasizes caring, diversity and inclusion, mutual respect, collaboration and service to our communities.  

      

    SUMMARY:  This position includes a variety of claim administrative and technical tasks that support a Claim Unit and/or outsourced vendor staff, as well as the entire Claim & Customer Service Department. The responsibilities of a Senior Claim Analyst may vary depending upon the needs of the Unit/Department.

     

    In addition to these tasks, the Senior Claim Analyst is responsible for all of the same tasks as a Claim Analyst including providing quality service by timely and accurately processing medical, dental, vision, disability or other claims for assigned groups, according to established plan documents and claim processing guidelines; serving as a back-up to Customer Service for overflow calls and could be responsible for working with providers, employees/members and clients to accurately respond to telephone or electronic inquiries regarding benefits, eligibility, and claims status.

     

    RESPONSIBILITIES INCLUDE:

    • Resolve client, employee/member, or provider issues regarding escalated or complex claims.
    • Review and release over-authority claims up to limit specified by corporate policy.
    • Handle claim referrals, including pre-determinations, using internal and external resources as needed. Advise Claim Analysts and/or outsourced vendor regarding claim processing.
    • Handle network referrals (e.g. CIGNA, AETNA, HHC Group) as well as PPO repricing disputes and appeals.
    • Handle appeals including research, response and tracking.
    • Process claim corrections, HDHP reconciliations, integrated deductible/out-of-pocket reconciliation and refund coordination.
    • Review, analyze and interpret claim forms, medical bills and reports to determine nature of illness/injury.
    • Determine benefit coverage based on system plan and clinical edits, plan documents and booklets, benefit reference documents, Claim Reference Manuals and claims-related memoranda, and reports.
    • Appropriately investigate, pend and refer claims based on claim procedures and guidelines.
    • Handle correspondence, pending claims and referrals in a timely manner based on claim procedures and guidelines.
    • Correctly and timely adjudicate claims using PowerSTEPP and WorkQueue based on the above.
    • Handle complex or technical claim adjudication using internal and external resources as needed, e.g. transplants, experimental & investigational, chemotherapy, etc.
    • Process vendor invoices in the claim system, e.g. Optum, Biologics, IRO’s, Medical Record Fees, etc.
    • Mentor and assist with onboarding new Analysts. Review and release Trainee work.
    • Test claims for new client and renewal changes to ensure benefits are set-up correctly.
    • Other duties as needed/assigned

     

    QUALIFICATIONS:

    • Minimum three years of medical claim processing experience
    • Ability to work in a fast-paced, customer service & production driven environment
    • Excellent verbal and written communication skills
    • Ability to work effectively with employees/members, providers, clients and differing levels of co-workers including Client Managers and all levels of staff
    • Ability to use common sense understanding to carry out instructions furnished in oral, written or diagram form
    • Flexible; open to continued process improvement
    • Self-directed individual who works well with minimal supervision
    • Good leadership, organizational and interpersonal skills
    • Demonstrated critical thinking skills
    • Ability to effectively deal with problems in varying situations and reach resolution
    • Ability to read, analyze and interpret documents and Summary Plan Descriptions (SPDs)
    • Ability to learn new/proprietary systems, to adapt to various system platforms, and to effectively use MS Word/Excel

     

    Come join Health Benefits! Join a team that will not only utilize your current skills but will enhance them as well. Trustmark benefits include health/dental/vision, life insurance, FSA and HSA, 401(k) plan, Employee Assistant Program, Back-up Care for Children, Adults and Elders and many health and wellness initiatives.  We also offer a Wellness program that enables employees to participate in health initiatives to reduce their insurance premiums.

     

    If you are a Colorado or New York resident and this role is a field-based or remote role, you may be eligible to receive additional information about the compensation and benefits for this role, which we will provide upon request.

     

    All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, sexual identity, age, veteran or disability.

     

    Required Skills Required Experience

  • Qualifications

     

    • High School diploma or equivalent of a GED or equivalent knowledge and skills acquired through on the job training or experience.

    • An associate degree in mechanical and/or industrial engineering preferred but not required