Job Title: Claims Processing Clerk

Department: Provider Relations

Reports to: Claims Administration Supervisor

Position Summary:

The Claims Processing Clerk will play a crucial role in maintaining efficient operations within a high-volume, fast-paced environment. The primary responsibilities will involve administrative support tasks including scanning, importing documents, data entry, responding to internal and external customer requests and managing various other claims-related processes. The Claims Processing Clerk will perform other clerical and administrative duties to help ensure smooth workflow and productivity.

Essential Functions:

• Sort, scan, classify incoming documents, ensuring accurate data entry and seamless integration into our software systems. 
• Manage the medical bill payment process by identifying and reporting errors to management. Submit resolutions for identified errors and, for more complex issues, collaborate with management to implement effective solutions.
• Prepare and scan documents into the imaging system, providing quality assurance for all documents scanned.
• Provide customer service, by assisting claimants and providers. Provide clear and concise information regarding general claim instructions and billing inquiries. Direct complex or specific questions to the appropriate team members or departments for further resolution.
• Coordinate accommodations for injured workers.
• Ensure the accuracy of payment processes for Pharmacy Benefit Management (PBM) and Medical Case Management (MCM). Maintain, open and update reports, including JIRAs, to support compliance and operational effectiveness.
• Manage refund requests in a timely and efficient manner, ensuring compliance with company policies and procedures. 
• Investigate and resolve issues with returned checks, communicating with customers to arrange for alternate forms of payment if necessary. 
• Enter new First Reports of Injury information accurately into claim system.
• Contact insured or other involved individuals to obtain any missing claim information.
• Serve as back-up for any claims administration duties within the Provider Relations Department   

Job Qualifications:

Education:

High School diploma or GED equivalent

Experience:

1-3 years directly related experience 

Required Skills/Abilities:

• Excellent customer service skills 
• Strong verbal and written communication skills with ability to communicate professionally with stakeholders 
• Ability to organize and prioritize work 
• Intermediate computer skills and ability to learn new computer applications
• Ability to meet deadlines and respond well to direction 
• Follow-through on commitments; is reliable, conscientious and dependable

Specialized Knowledge, Licenses, etc.:

Demonstrated proficiency in: 

• Windows-based PC software (Word, Excel, Outlook, etc.).
• General knowledge of payer specific or medical specialty billing, as well as knowledge of ICD-9, ICD-10 and CPT coding helpful.

Values and Mission:

Adheres to New Mexico Mutual’s values and mission by demonstrating Service Excellence, Trust, Ownership, One Team and Boldness in thought and action.

Positive Attitude:

Develops and maintains positive working relationships with team members, customers, co-workers, and management by demonstrating effective communication and collaborative skills.

Working Conditions:

• NEW MEXICO MUTUAL maintains general office conditions with light physical demands.
• Employees of NEW MEXICO MUTUAL adhere to all safety rules and regulations including building security.
• Employees participate in ensuring safe and efficient operating conditions that safeguard employees and facilities.
• NEW MEXICO MUTUAL maintains a drug free environment; drug testing prior to employment as well as upon a work-related accident.
• Exposure to VDT screens.