Claims Representative I - PSA - (Springfield, IL)

Accurately interpret regulatory guidelines for claims processing. Review and research claims and determine coverage based on plan documents and claims processing guidelines. Adjudicate claims for payment or denial within PacificSource Administrators standards for quality and production. Accurately process claims by researching benefits and claims policy and procedures. Research includes, but is not limited to: Reading and understanding all related account and claim notes Comparing procedures to diagnostic codes Determine eligibility based on service date and plan parameters Accurately enter claims to prevent duplicate reimbursements or overpayments Review claims for inconsistencies between billed and election amount Adjudicating point of sale transactions 2. Verify accurate data entry including member details, plan year, coding, dollar amounts and if required, denial code. 3. Release claim for payment or denial when research is complete, and claim is accurately adjudicated. 4.