CLAIMS PROCESSOR – FSA, HRA & Lifestyle Claims
Position Summary:
The Claims Processor is responsible for accurately and efficiently adjudicating Flexible Spending Account (FSA), Health Reimbursement Arrangement (HRA), and Lifestyle Benefit claims in accordance with applicable plan provisions, client requirements, eligibility guidelines, work instructions, and Company procedures.
The Claims Processor reviews submitted claims and supporting documentation, determines claim eligibility, processes approved or denied claims, identifies claims requiring additional information or review, and ensures claims are completed within established turnaround and service level requirements.
The position requires strong attention to detail, the ability to interpret plan requirements, and the ability to consistently meet established quality and productivity standards.
Essential Duties and Responsibilities:
Claims Adjudication
- Review and adjudicate FSA, HRA, and Lifestyle Benefit claims accurately and efficiently using established processing work instructions.
- Review claims for completeness, eligibility, required documentation, and compliance with applicable plan requirements, including but not limited to pharmacy, over-the-counter items, dental, orthodontia, vision, medical, parking, mileage, premiums, and childcare.
- Verify that supporting documentation contains required information, including, as applicable: Provider, Date of service, Applicable fund or coverage dates, Patient responsibility, Service category, and Description of service
- Review documentation and applicable eligibility guidelines to determine whether expenses qualify for reimbursement.
- Determine whether claims are duplicates of previously submitted or processed claims.
- Approve, deny, partially approve, pend, or request additional documentation in accordance with established procedures, processing reason codes, and client-specific guidelines.
- Calculate patient responsibility, when applicable, by accurately accounting for insurance payments, adjustments, rebates, discounts, and other applicable amounts.
- Enter accurate and appropriate permanent notes in the applicable claims processing system to document claim adjudication and decisions.
- Apply client-specific plan provisions, eligibility requirements, and processing procedures consistently.
- Escalate claims requiring additional clarification, research, or review to the appropriate review queue or Team Leader.
- Process claims within established client turnaround requirements and service level agreements.
- Maintain an average processing rate of 75–80 claims per hour, based on the applicable workflow and claim complexity.
- Maintain a minimum claims adjudication accuracy rate of 98%.
- Participate in coaching, retraining, and quality improvement activities when processing or audit concerns are identified.
- Demonstrate continuous improvement based on audit results, coaching, and feedback.
- Promptly communicate questions, concerns, recurring claim issues, or unclear processing requirements to the Team Leader.
- Follow all current Company and client-specific work instructions and procedures.
- Maintain and follow the Company's Clean Desk Policy and Dress Code Policy.
- Follow all Company security, privacy, confidentiality, and information protection policies, standards, and guidelines when handling participant, client, employee, and Company information.
Quality and Audit Responsibilities
- Participate in routine claim audits and quality reviews.
- Review audit feedback and correct identified processing errors.
- Apply audit findings to future claims processing.
- Maintain the required 98% or greater accuracy standard.
- Notify the Team Leader of recurring errors, unclear guidelines, or potential issues with client requirements.
- Participate in additional training when audit results indicate a need for improvement.
Training and Process Updates
- Complete required initial and ongoing training related to FSA, HRA, and Lifestyle Benefit claims.
- Maintain knowledge of current eligibility requirements, benefit categories, client-specific requirements, and processing procedures.
- Review and incorporate updates to work instructions and eligibility guidelines into daily processing.
- Complete training claims accurately and in accordance with established training requirements.
- Ask questions and seek clarification when processing requirements are unclear rather than making assumptions.
Productivity and Attendance
- Meet established daily productivity, quality, and turnaround expectations.
- Maintain an average processing rate of 75–80 claims per hour, when applicable to the assigned workflow.
- Maintain a minimum 98% claims adjudication accuracy rate.
- Maintain regular and reliable attendance in accordance with Company policy.
- Be ready and available to perform assigned duties at the beginning of the scheduled work period.
- Follow Company procedures for requesting time off, reporting absences, and recording time worked.
- Obtain appropriate management approval before working overtime.
KEY ACCOUNTABILITIES:
- Accuracy
- Timeliness
- Productivity
- Communication Skills
- Problem Solving
- Attention to Detail
- Accountability
- Reliability and Attendance
- Policy and Procedure Compliance
MINIMUM REQUIREMENTS:
- Computer literate
- High school diploma or GED required.
- Excellent analytical and critical thinking skills
- Detail-oriented
- Reliable
- Ability to work independently and collaboratively within a team.
Job Type: Full-time
Pay: From $17.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Physical Setting:
Experience:
- Microsoft Office: 1 year (Preferred)
- Clerical: 1 year (Preferred)
Work Location: In person
