Claims Adjudicator

4 weeks ago
# of Openings
Medical Claims





Looking for a way to influence the health and healthcare of many?


If so, we’d love to hear from you! Our mission-driven organization is focused on theTriple Aim - Better Health, Better Healthcare and Lower Costs to individuals and their families who participate in our health plans.


UNITE HERE HEALTH serves 90,000+ workers in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!



Key Attributes:


  • Integrity – Must be trustworthy and principled when faced with complex situations
  • Ability to build positive work relationships – Mutual trust and respect will be essential to the collaborative relationships required
  • Communication – Ability to generate concise, compelling, objective and data-driven reports
  • Teamwork – Working well with others is required in the Fund’s collaborative environment
  • Diversity – Must be capable of working in a culturally diverse environment
  • Continuous Learning – Must be open to learning and skill development.  As the Fund’s needs evolve, must be proactive about developing new areas of expertise
  • Lives our values – Must be a role model for the Fund’s BETTER Culture and Mission (Better, Engage, Teamwork, Trust, Empower, Respect)



The purpose of this position is to receive, examine, verify and input submitted claim data, determine eligibility status, and review & adjudicate claims within established timeframes. Will effectively utilize the RIMS/Javelina claim processing system and the IMAX document retrieval system in order to perform the day to day job functions of processing claims.


  • Screen claims for completeness of necessary information.
  • Verify participant/dependent eligibility.
  • Interpret the plan benefits from the SPD/Plan Documents.
  • Code basic information and select codes to determine payment liability amount.
  • Based on established guidelines, evaluate diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered.
  • Determine the need for additional information or documentation from participants, employers, providers and other insurance carriers.
  • Research claims, initiate corrections, update history and refer claims to appropriate personnel.
  • Request overpayment refunds, maintain corresponding files and perform follow-up actions.
  • Maintain related claim adjudication manuals, SPD’s, memos and reference material updates.
  • Meet or exceed established productivity and quality goals; monitor inventory aging to select and process claims within established time frames.
  • Handle assigned claims on a first-in, first-out basis, regardless of complexity/difficulty.
  • Process claim adjustments.
  • Address and resolve Customer Service Inquiries on a timely basis.
  • Performs other duties as assigned within the scope of responsibilities and requirements of the job.


  • High School Diploma / GED
  • College coursework in area of medical terminology, ICD9 and CPT codes is a plus
  • Technical training in the area of medical terminology, ICD9 and CPT codes is a plus
  • Minimum of 2 years experience in a group medical claim adjudication environment is desirable

  • Knowledge of the RIMS computer system is helpful

  • Experience with interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits; and experience with eligibility verification, medical coding, coordination of benefits and subrogation

  • Minimum level computer skills in a Microsoft Office environment: Beginner-Intermediate

  • Bi- or Multi- lingual skills (written and verbal): A Plus

  • Effective communication skills, both orally and in writing is required

Ability to:

  • Maintain established production levels and excellent quality
  • Work effectively as a team member within a team-oriented structure is also an important requirement of the position
  • Keyboard 50 wpm
  • Manage competing deadlines and multiple projects in a fast-paced environment
  • Perform the essential functions of this job with or without reasonable accommodation


Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
Share on your newsfeed