Job Details

Independently processes medical, dental, and hospital claims including complex cases, provides customer service, and manages special projects such as subrogation. Acts as a lead and resource for other claims processing positions.

Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role.

Key Duties And Responsibilities

• Processes medical, dental, and/or hospital claims; processes complex claims independently.
• Provides customer service by responding to and documenting telephone and/or written inquiries.
• Meets quantity and quality claims processing standards.
• Performs pre-authorizations, audits files, requests check tracers and stop payments, and assists with researching and preparing appeals, as applicable.
• Maintains current knowledge of assigned Plan(s) and effectively applies knowledge in the payment of claims, customer service and all other job functions.
• Handles special duties and higher level, more complex functions (i.e. third party liability/subrogation, Flex, re-insurance, PPO updates, life insurance, etc.) as assigned.
• Acts as resource or "lead" for all processor positions by answering questions, providing assistance, conducting training, and providing back‑up on all other accounts.
• Consistently meets established performance standards and demonstrates excellent attendance and punctuality.
• Performs other related duties and special projects as assigned.

Working Conditions / Physical Effort

• Normal degree of physical effort in typical office environment with comfortable, constant temperatures and absence of objectionable elements.
• May be subject to interruptions.
• May be required to lift a maximum of 25 lbs.
• Must be able to have flexible work schedule when workflow requires.
• Must meet established attendance and punctuality guidelines.

Minimum Qualifications

• High School Diploma or Equivalent.
• Three years of experience processing all types of group medical, dental and hospital claims; in-depth knowledge of benefits, claims adjudication principles and procedures, medical and/or dental terminology and ICD-9 and CPT-4 codes.
• Excellent organizational skills, attention to detail, and ability to interact effectively with others.
• Effective oral and written communication skills.
• Excellent mathematical aptitude.
• Solid organization skills with strong detail orientation/high degree of accuracy.
• Possess a strong work ethic and the ability to work effectively in a team environment.
• Highly developed sense of integrity and commitment to customer satisfaction.
• Ability to communicate clearly and professionally, both verbally and in writing.
• Ability to type 35 WPM and use a 10-key; proficient PC skills, including MS Word and Excel.
• Ability to perform well under pressure and to juggle many projects simultaneously.
• Excellent business writing skills.
• Ability to read, analyze and interpret general business materials, technical procedures, benefit plans and regulations.
• Able to maintain excellent attendance and punctuality.
• Note: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee of this job. Duties, responsibilities and activities may change at any time with or without notice.

Disability Accommodation

Consistent with the Americans with Disabilities Act (ADA) and other applicable federal and state law, it is the policy of Zenith American Solutions to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Recruiting Department at ...@zenith-american.com, and we would be happy to assist you.

Compensation: $37.28 per hour.

About the Company

Zenith American Solutions is the largest independent third‑party administrator in the United States and currently operates over 44 offices nationwide. Established as a result of a merger between Zenith Administrators and American Benefit Plan Administrators in 2011, the company combines resources, best practices, and scale to offer high‑quality service.

We are looking for a dedicated, energetic employee with the necessary skills, initiative, and personality, along with the desire to get the most out of their working life. You will be part of an environment where employees and clients truly matter.

Our comprehensive benefits program includes health, vision, and dental coverage, a retirement savings 401(k) plan with company match, paid time off (PTO), opportunities for growth, and more.

Seniority level: Mid–Senior Level

Employment type: Full‑time

Job function: Other

Industry: Human Resources Services

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