• Claims Adjuster IV

    Job Locations US-VA-Glen Allen
    Job ID
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
    If this sounds like you, read on!


    The Claims Adjuster IV is responsible for the accuracy and timely testing of claims processed according to the benefit structure to ensure accurate adjudication of healthcare claims payment.  This position requires a very strong knowledge base of all claim types and must have the ability to adjudicate all claim types. The Claims Adjuster IV is also responsible for communicating with internal and external customers on the outcome of claims processed as well as the status of claims projects.  It is expected that a Claims Adjuster IV is able to train existing staff on the claims adjudication process and serve as a point of contact to internal team members with complex claims questions.


    • Ability to test claims according to benefit structure, fee schedule and medical payment policies.
    • Ability to process claims efficiently, timely and accurately
    • Possess excellent analytical skills and deliver methodical approach to resolution.
    • Work as a unit/team in resolving claims issues or special projects
    • Effectively communicates analysis results clearly and concisely.  Communicate with internal personnel, vendors, providers, and billing representatives about claim related issues via writing, fax, etc.
    • Master a thorough understanding of such claim types as Nursing Facility, Home Health, and EDCD Waiver Services, Early Intervention, Coordination of Benefits, Hospice, ARTS, CMHRS, etc.
    • Master a thorough understanding of such items as HCPC and Procedure codes, Revenue Codes, modifiers and their effect on reimbursement; appropriate billing guidelines for anesthesia claims, dialysis, durable medical equipment (DME), and Home Health Services.
    • Report any inconsistencies that are identified in regards to internal department policies and procedures or potential billing issues to Management
    • Work with the Management to ensure that all existing workloads have been addressed and are within acceptable time frames
    • Coach/Train lower level associates
    • Create and Maintain Claims Processing SOPs
    • Participate in Projects as the SME
    • The ability to work overtime as needed
    • Perform other duties as assigned



    • High school diploma
    • Associates Degree in Business or Healthcare Preferred


    • Strong background and knowledge of Claims Processing Systems
    • Strong organizational, written, and verbal skills
    • Exposure to health care environment and in-depth knowledge of CMS  1500 and UB04 claim forms
    • CPT,HCPCS, ICD9/ICD10 knowledge
    • Ability to work independently and in a team environment
    • 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


    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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