• Day-to-day processing of claims for accounts: • Responsible for processing of claims (medical, dental, vision, and mental health claims) • Claims processing and adjudication. • Claims research where applicable. • Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic). • Incumbents are expected to meet and/or exceed qualitative and quantitative production standards. • Investigation and overpayment administration: • Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers. • Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records. • Utilize systems to track complaints and resolutions. • Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading.