Req ID: 222797

NTT DATA Services strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now.

We are currently seeking a Facets Claims Examiner to join our team in Philadelphia, Pennsylvania (US-PA), United States (US).

The Claims Examiner is responsible for accurate and timely adjudication of claims for the Health Plans lines of business.

Job Description:
Primary duties include analysis and resolution of claims, including coding principles, benefits, pricing, and potential third-party liability. The claims examiner must be able to work independently, effectively prioritizing work in a production environment that frequently changes to meet production standards and contractual requirements. The Claims Examiner must maintain production and inventory standards compliant with Claims Administration requirements. Success in this position will be based on the individual's ability to effectively prioritize work, identify, and resolve complex concerns in a professional manner, and work in a team environment to achieve and maintain production and inventory standards.

Responsibilities:

• Timely and accurate processing and adjudication of all types of claims from assigned workflow queues.

• Compliance with state, federal and contractual requirements to Claims Administration.
• Demonstrate a thorough knowledge of the Plan's claims processing procedures as provided in training materials and proficiency with the core and ancillary system applications.
• Demonstrates the ability to think analytically to resolve complicated claim issues and identify appropriately when to escalate issues for review.
• Demonstrates a thorough knowledge of regulatory requirements, individual plan benefits, provider contracts, policies, and procedures for product assignment.
• Claim analysis of coding and billing compliance, potential third-party liability, accurate coordination of benefits (COB), benefit application including limitations and restrictions, pre-existing conditions, subrogation, medical necessity and other claim investigation as appropriate.
• Accurate and timely review of claim pricing to facilitate manual pricing as necessary, working with various Health Plan provider networks.
• Complete all mandatory claims training/refresher courses.
• Effectively communicates with members and providers verbally and in writing regarding claim issues including claim adjudication, subrogation, and overpayments or billing problems.
• Actively participates and supports department and organization-wide efforts to improve efficiencies while supporting departmental goals and objectives.
• Complete all mandatory compliance and corporate training.
• Must be able to adapt to a changing work priorities and requirements and perform other duties as directed to support the overall functions of Claims Administration and support of staff without boundaries within the Plan.
  

Basic Qualifications:

• High school diploma or equivalent required.
• 3+ years of full-cycle medical claims processing (Pay, Pend, Deny) in health insurance industry
• 1+ year of Facets experience
  

Where required by law, NTT DATA provides a reasonable range of compensation for specific roles. The starting hourly range for this remote role is $16.00 to $16.75 hourly rate. This range reflects the minimum and maximum target compensation for the position across all US locations. Actual compensation will depend on several factors, including the candidate's actual work location, relevant experience, technical skills, and other qualifications. This position may also be eligible for incentive compensation based on individual and/or company performance.

This position is eligible for company benefits that will depend on the nature of the role offered. Company benefits may include medical, dental, and vision insurance, flexible spending or health savings account, life, and AD&D insurance, short-and long-term disability coverage, paid time off, employee assistance, participation in a 401k program with company match, and additional voluntary or legally required benefits .

About NTT DATA Services

NTT DATA Services is a global business and IT services provider specializing in digital, cloud and automation across a comprehensive portfolio of consulting, applications, infrastructure and business process services. We are part of the NTT family of companies, a partner to 85 % of the Fortune 100.

NTT DATA Services is an equal opportunity employer and considers all applicants without regarding to race, color, religion, citizenship, national origin, ancestry, age, sex, sexual orientation, gender identity, genetic information, physical or mental disability, veteran or marital status, or any other characteristic protected by law. We are committed to creating a diverse and inclusive environment for all employees. If you need assistance or an accommodation due to a disability, please inform your recruiter so that we may connect you with the appropriate team.