Claims Adjudicator I

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference working in everything from scrubs to jeans.

Are we growing? Absolutely and Globally. In 2021 we grew our teams by almost 50% and continue to grow even more in 2022. Are we recognized as a company you are supported by for your career and growth, and a great place to work? Definitely. Evolent Health International (Pune, India) has been certified as “Great Places to Work” in 2021. In 2020 and 2021 Evolent in the U.S. was both named Best Company for Women to Advance list by Parity.org and earned a perfect score on the Human Rights Campaign (HRC) Foundation’s Corporate Equality Index (CEI). This index is the nation's foremost benchmarking survey and report measuring corporate policies and practices related to LGBTQ+ workplace equality.

We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

What You’ll Be Doing:

Job Description: Claims-Adjudicator I

Essential Functions:

• Basic understanding on US health insurance claims (CMS-1500 & UB04) adjudication. Providing strong analytical skills to review inpatient and outpatient facility claims with multiple and bilateral surgical services, complex anesthesia services, other professional services, preauthorization requirements, high dollar claims, DME, third-party liability and coordination of benefits.
• Assist and present knowledge share information with team members as needed.
• Responsible for adjudicating claims to maintain/comply with Service Level Agreements
• Determine accurate payment criteria for clearing pending claims based on defined Policy and Procedures.
• Ability to understand logic of standard medical coding (i.e. CPT, ICD-10, HCPCS, etc.)
• Research CMS1500 claim edits to determine appropriate benefit application utilizing established criteria, apply physician contract pricing as needed.
• Ability to resolve claims that require adjustments and adjustment projects.
• Identify claim(s) with inaccurate data or claims that require review by appropriate team members.
• Maintain productivity goals, quality standards and aging timeframes.
• Contribute positively as a team player.
• Complete special projects as assigned.
• Comply with all departmental and company Policy and Procedures
  
  
  

Education and Experience:

• Associate or bachelor's degree preferred.
• Experience in US health insurance claims processing with a minimum of 0 to 3 years adjudication experience.
• HMO Claims or managed care environment preferred.
  
  
  

Skills:

• Ability to work in a team environment.
• Integrity and discretion to maintain confidentiality of members, employee and physician data.
• Knowledge of medical billing and coding
• Knowledge of health insurance, HMO and managed care principles
• Critical thinking skills and analytical ability to work, discover and outline systems related issues independently and within a team to provide resolution to work products.
• Excellent interpersonal, oral and written communication skills
• Strong attention to detail and organization
• Able to work independently, strong analytic skills.
• Strong computer skills
  
  
  

Mandatory Requirements:

We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.