QUALIFICATIONS: REQUIRED TESTING: JEPS Math REQUIRED: Ability to learn nonroutine, complex problem-solving skills in a structured, formalized training environment, demonstrated by having the following: High school diploma or GED The ability to make judgments regarding covered services and to resolve complex coverage issues as demonstrated by: 1) successful completion of 12-months as a HealthPartners Claims Examiner, or, 2) two-years work experience as a claims examiner independently analyzing and processing nonroutine complex medical claims at another employer. Basic mathematics aptitude Must possess keyboard skills Keystroke competency and 10-key skills Demonstrate independent analytical problem-solving skill Written and oral communication skills PHYSICAL REQUIREMENTS: Ability to sit for prolonged periods of time. This position requires manual dexterity and close visual perception. Applicant must be able to read, write and speak English. POSITION PURPOSE: Service excellence is to be centered on patient care and patient relationships and is the responsibility of all employees. Teamwork is the norm and all employees will be held accountable to work as effective team members. To train on the HP DEC claim process, procedure and system, including, but not limited to, the following related subjects: Plan Design & Benefits Care Systems & Networks Claim Types Department Work Flows & Processes DEC System, Screens and Coding Automated Document Inventory System CFU Tracking & Trending System / HCSS Routing Standard Product Claims Standard Product MH/CD Claims Corporate Audit Standards to achieve and maintain Productivity Standards to achieve and maintain Authorization To learn, demonstrate and perform timely and accurate adjudication of Primary Care claims for payment or denial. ACCOUNTABILITIES: Examine claim forms, electronic claims and other records to verify Plan coverage and determine if other insurance coverage is applicable. Review forms, electronic claims and related documents for completeness. Assign appropriate coding as necessary to determine benefits. Correspond (by letter, telephone and in person) with members, employers, providers of service and other HealthPartners personnel regarding missing data and coverage determinations. Review and determine primacy rules according to NAIC guidelines Identify and interpret Explanation of Benefits received from multiple carriers Coordinate benefits with multiple financially-responsible parties according to NAIC guidelines Determine benefit coverage through interpretation of plan provisions, policies and procedures, including coordination of benefits. Adjudicate Primary Care claims for payment, denial, or disallowance in accordance with plan provisions, policies and procedures. Perform system overrides to manually calculate the amount of benefit for claims when plan benefits and provider arrangements allow for multiple options and the system is unable to automate the calculation. Resolve system error edits. Make judgements regarding covered services through a review of patient history and the appropriate application of plan policies and procedures. Respond to member correspondence / telephone inquiries submitted through the member services area regarding claim adjudication and determinations. Meet established production and quality, pend management and aged-document management standards. Perform adjustments to previously processed claims as required to correct payment detail or online information. This includes all overpayment and underpayment claims. Perform other duties as assigned by HealthPartners Claims Department management. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.