Claims Adjudicator III

UNITE HERE HEALTH is seeking a Claims Adjudicator III to support complex healthcare claims processing, benefit interpretation, escalated issue resolution, and operational excellence within the claims department. This position serves as a senior-level claims resource responsible for processing and adjudicating medical, vision, dental, disability, Medicare Secondary Payer, Personal Injury Protection, and subrogation-related claims.

This Claims Adjudicator III role fits best as a moderate-phone position. Daily responsibilities involve claim adjudication, documentation review, benefit analysis, research, and issue resolution. Team members also handle escalated member, provider, vendor, and insurance-related inquiries, making communication an ongoing component of the role.

Key responsibilities include reviewing and adjudicating complex healthcare claims, verifying eligibility, interpreting plan documents, researching claim issues, processing Medicare Secondary Payer files, handling Personal Injury Protection claims, managing disability claims, and resolving subrogation-related matters. The position also requires evaluating claim accuracy, requesting additional documentation, and ensuring compliance with healthcare regulations and benefit plans.

Additional duties include supporting team training initiatives, mentoring peers, identifying process improvement opportunities, coordinating with vendors, managing claim adjustments, handling overpayment recoveries, and contributing to departmental productivity and quality goals. The role serves as a subject matter expert and works closely with supervisors and team leaders to improve operational performance.

Successful candidates possess extensive healthcare claims adjudication experience, knowledge of healthcare regulations, understanding of benefit plans, strong analytical abilities, excellent communication skills, and the ability to manage multiple priorities within a fast-paced environment.

The position offers a pay range of $23.79 to $29.13 per hour along with medical, dental, vision, retirement benefits, paid time off, tuition assistance, disability coverage, life insurance, and additional employee benefits.

Overall, this role is ideal for experienced healthcare claims professionals who enjoy benefit analysis, claim adjudication, problem-solving, regulatory compliance, and complex healthcare operations.