Medical Claims Processor

FEP Claims Processor Position Summary:

We are seeking a detail-oriented and experienced Claims Processor/Adjuster to join our team. This role is responsible for the accurate and timely processing and adjustment of facility and ancillary claims submitted by members or providers. The ideal candidate will have experience with FEP claims, excellent problem-solving skills, and the ability to work effectively in a production environment.

Key Responsibilities:

• Accurately process and adjust facility and ancillary claims in accordance with company policies and regulatory guidelines.
• Research and resolve claim adjustment requests received from both internal and external stakeholders, including providers and other health plans.
• Perform claim payment adjustments, ensuring all transactions follow documented guidelines and standards.
• Investigate overpayments and underpayments; initiate recovery actions and ensure accurate transactional corrections.
• Respond to internal and external inquiries professionally and within service-level agreements.
• Meet and maintain departmental quality and production benchmarks.
• Provide timely feedback, updates, and estimated resolution dates on complex claim issues.
• Participate in work groups and complete special projects as assigned.
• Perform other related duties as needed to support the team and organizational goals.

Education & Experience:

• 2–4 years of hands-on experience processing and adjusting FEP claims in a production environment.
• Experience working with the FEP Direct application preferred.
• High school diploma or equivalent required.

Skills & Competencies:

• Strong math and reading comprehension skills.
• Proficient in Microsoft Office Suite, especially Excel and Word.
• Ability to research and interpret data across multiple systems and sources.
• Excellent verbal and written communication skills.
• Strong interpersonal and customer service skills.
• High attention to detail with solid organizational and time-management abilities.
• Problem-solving mindset with the ability to work both independently and collaboratively.

Preferred:

• Prior healthcare or insurance industry experience.
• Familiarity with claims adjudication and medical billing practices.