Tufts Health Plan Looking for Complex Claims Processor-II at Remote Full Time

The Complex Claims Processor II is responsible for the timely and accurate processing of claim inventory as assigned by the Complex Claims Supervisor. Using analytical and problem solving skills, the Complex Claims Processor II is expected to fully research and resolve all complex issues and problem codes for each claim. Additionally, the Complex Claims Processor II may be assigned to work on claims processing and reporting for specific projects and for member reimbursements.

• Fully research and resolve all complex issues and problem codes so claim can properly adjudicate
• Manually apply specific product benefit rules to claim for adjudication
• Ensure claim payment is updated to correctly reflect Tufts Health Plan’s status as a primary or secondary payer through the appropriate coordination of benefits
• Determine member’s eligibility if in question.
• Check to determine if services rendered on the claim are allowable under the member’s benefit plan and/or the proper authorization, referrals and pre-registrations were obtained as required by the plan.
• Manually calculate and/or apply pricing to each claim when necessary
• May assist partner departments by providing support on complex claims issues
• Review and update product and/or inventory specific reports as assigned by the supervisor
• Communicate (verbally or written) with members and providers to answer and resolve questions
• Monitor pending claims daily and ensure claims are released timely for adjudication

• Provide subject matter expertise for Audit, departmental inquiries and other operational committees.
• Represent the Department in meetings, with both internal and external customers, in a professional manner.
• Process member reimbursement requests, working with the Fraud, Prevention & Recovery Unit and Customer Relations, to ensure timely and accurate results.
• Ensure compliance with all legal/regulatory requirements applicable to specific product or employer group specifications
• Analyze, trend and reconcile inventory variances between vendors, company alliances, employer groups and Tufts Health Plan.

• Achieve individual standards for quality and production as assigned by supervisor
• Contribute to team and departmental standards for quality and production
• Participate in identifying opportunities for overall process improvements

• Serve as SME for documentation and testing
• Act as a role model and mentor to core/complex claims processors
• Participate in initiatives or provide backup support to other areas of department as requested
• Participate in staff & individual meetings and training sessions as required
• Comply with all department and company guidelines and policies