Job Description

Principal Accountabilities & Responsibilities Responsible The individual(s) who actually do the job. The degree of responsibility is defined by the accountable person. Responsibilities can be shared. A Accountable “The Buck Stops Here” - The individual who is ultimately accountable - their neck is on the line if the job isn’t done! They have the power of veto. Only one ‘A’ can be assigned to an activity or decision. They can delegate the ‘R’ (or choose to do them) C Consulted “In the Loop” - The individual(s) who need to be consulted prior to a final decision or action being taken. This is TWO-WAY communication. Consulted may not have a direct part in the task but is impacted by its completion. Their input may be necessary. I Informed “Keep in the Picture” - The individual(s) who need to be informed after a decision or action is taken. This is ONE-WAY communication. Input from the informed party is not necessary - but they will need to know. They may be required to take action as a result of the outcome. Essential Duties & Responsibilities Reviewing healthcare claims and verifying submitted documents R Ensuring compliance with adjudication policies and guidelines R Identifying and flagging incomplete or incorrect claims R Processing claims based on eligibility and policy terms R Approving or rejecting claims as per defined authority levels A Consulting with team leaders or subject matter experts for complex cases C Informing stakeholders about claim decisions and outcomes I Preparing and submitting adjudication performance reports I 2 Job Specifications – For Grade / Level: Band 1 2.1 Qualifications and Technical Competencies Required