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Claims Adjuster III

Claims Adjuster III

Job Locations 
US-VA-Glen Allen
Job ID 

Job Description


The Claims Adjuster III is responsible for the accurate and timely processing of healthcare claims of high complexity and/or dollar amount received by the Claims Department. The Claims Adjuster III is also responsible for communicating with internal staff, vendors, providers, and billing representatives on the outcome of claims processed as well as the status of outstanding claims.  It is expected that a Claims Adjuster III is able to process pending claims of any type because of their level of processing experience.


  • Process claims accurately and within the time frames established by management using the claims document imaging system and the claims processing system as well as third party software and other established pricing tools.
  • Process claims that fall outside of the automated pricing process. This includes, but, is not limited to SNF, Home Health, Dialysis, and Inpatient claims.
  • Process Provider Refunds
  • Master a thorough understanding of such items as modifiers and their effect on reimbursement, coordination of benefits, appropriate general billing guidelines, matching of appropriate referrals and authorizations to claims.
  • Communicate with internal personnel, vendors, providers, and billing representatives about claim related issues via writing, fax, etc.
  • Work claims reports and special projects as directed by management
  • Report any inconsistencies that are identified in regards to internal department policies and procedures to the management
  • Work with the management to ensure that all existing workloads have been addressed and are within acceptable time frames
  • Provide management with required documentation to assist in the continued development of the department (e.g. Production totals, etc.)
  • Assist Manager and Supervisor with employee training and training materials.


MINIMUM EDUCATION REQUIREMENTS                                                                    

  • High school diploma or equivalent
  • Some College helpful 



  • Strong verbal and written communication skills
  • Strong organizational skills
  • Exposure to health care environment and in-depth knowledge of CMS 1500 and UB04 claim forms
  • CPT, HCPCS, ICD 10 knowledge
  • Ability to work independently
  • Ability to meet deadlines and work under pressure 



  • Minimum three (3) years claims processing and/or healthcare billing experience


  • Physical health sufficient to meet the ergonomic standards and demands of the position


About Us

Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


Our mission is to inspire healthy living within the communities we serve!

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