Claims Adjudication Associate

About Judi Health Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels. At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health . Location : Hybrid 3 days in Charlotte office Position Summary:   Judi Health is seeking a self-driven Claims Adjudication Associate to support the Medical claims adjudication workflow for JUDI Health, our enterprise health platform.   In year one, this individual will train on the JUDI Medical adjudication system. This individual will be responsible for maintaining the operational adjudication process, member, and provider escalated inquiry management, subrogation, stop-loss, recoupment and adjustment flows, and adhering to standard and contractual claims processing SLAs.   In year two, this individual will be responsible for managing and servicing new and existing clients of JUDI’s Medical Claims Adjudication platform. This individual will be expected to maintain an in-depth understanding of the evolving capabilities of JUDI and our medical network support and client base. Exceptional communication skills and attention to detail are critical for communicating with internal and external stakeholders to build holistic support for medical claims processing.   Position Responsibilities:   Review, assess, and make decisions on medical claims submitted by networks, claimants, or other parties.    Provide support to Customer Care representatives in relation to claims and benefits questions from Members and Providers.   The Claims Adjudicator reviews the facts of each case and applies the applicable laws, regulations, and policy provisions to determine the appropriate claim outcome.    The Claims Adjudicator must be knowledgeable of the claims process, laws, and policies, as well as possess excellent communication skills and a commitment to providing outstanding customer service.    Manually adjudicate claims received via 837 EDI file, HIPAA 1500 or UB-04 forms, or direct member reimbursement submissions via superbill submission.   Adhere to standard SLA’s regarding number or percentage of claims processed per day   Assist in management of claims related mail workflows including Appeals, subrogation, payments, and stop-loss.   Build and maintain trusting relationships with clients through superior customer service.   Assist in communications throughout the implementation process, including detailed and strategic guidance for adjudication infrastructure, processing, reporting, inquiry management, and complex claim situations/requests.   Proactively identify execution risks and mitigation strategies.   Identify and drive efficiencies to automate adjudication flows and reduce risk.   Certain times of year may require meeting participation, service support or other requirements outside of standard business hours, including weekends.   Responsible for adherence to the Judi Health Code of Conduct including reporting of noncompliance.   Minimum Qualifications:   Bachelors degree strongly preferred   Experience managing a team of direct reports   1+ years of work experience at a health plan, claims adjudicator, or TPA   Well-versed in Benefit determinations   Well-versed in impact of claims processing and adjudication in regards to COB, Adjustments, Appeals, and member/provider inquiries   Act as a patient advocate, protecting privacy and confidentiality issues.   Track record of leading cross-functional initiatives, driving high performance, meeting deadlines, and executing on deliverables   Exceptional project / time management, prioritization, and organizational skills to ensure customer satisfaction   Ability to shift between competing priorities and meet organizational goals   Proficient in Microsoft office Suite and willing to adapt to software such as Jira, Miro, Confluence, Github, and AWS Redshift   Excellent verbal, written, interpersonal and presentation skills   Ability to work effectively with virtual teams   Preferred Qualifications:   Medicare/Medicaid experience preferred   Charlotte, NC Salary Range $82,400 — $103,000 USD All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals. We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.   By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found at   https://www.judi.health/legal/privacy-policy .

laptop-ats-crawler v3