Claims Adjuster

Job Summary

Working remotely, the full-time C & S Out of Pocket Claims Adjuster will manage the resolution of Maximum Out-of-Pocket (MOOP) overages and discrepancies for Dual Eligible Special Needs Plan (DSNP) members, conducting root cause analysis and collaborating with various teams to enhance claims processing and member experience.

Key responsibilities:

• Review and resolve DSNP MOOP overages and accumulator discrepancies
• Conduct detailed root cause analysis and identify trends impacting claims and member benefits
• Collaborate with internal and external partners to implement process improvements and ensure compliance

Required qualifications:

• High School Diploma / GED or equivalent work experience
• 1+ years of claims adjustment experience within CSP Facets
• Experience in researching and resolving complex claims and accumulator issues
• Ability to perform root cause analysis and identify trends
• Experience in healthcare operations, claims processing, or government healthcare programs