Job Description

Job Description

Job Description

About the Role:

A Taft-Hartley Fund Claims Adjuster is responsible for reviewing, processing, and resolving claims related to employee benefits under Taft-Hartley multi-employer benefit plans.

Minimum Qualifications:

• High school diploma or GED required.
• 2+ years of experience in claims processing, benefits administration, or healthcare-related customer service.
• Knowledge of ERISA, HIPAA, COBRA, and other employee benefits laws.
• Strong attention to detail, analytical, and problem-solving skills.
• Proficiency in claims processing software, Microsoft Office Suite (Excel, Word, Outlook), and data entry systems.
• Strong verbal and written communication skills.
• Ability to manage a high volume of claims and meet strict deadlines.

Preferred Qualifications:

• Experience with Taft-Hartley multi-employer benefit plans or union benefits.
• Bilingual in Spanish or Polish (preferred but not required).
• Experience handling appeals and claim audits.
• Strong customer service skills with the ability to de-escalate conflicts and resolve disputes.

Responsibilities:

• Review and process medical, dental, vision, disability, and other benefit claims in compliance with Taft-Hartley regulations and plan guidelines.
• Verify participant eligibility, coverage, and plan provisions before approving or denying claims.
• Investigate claims, request additional documentation if needed, and ensure compliance with federal laws such as ERISA, HIPAA, and the Affordable Care Act (ACA).
• Communicate with plan participants, healthcare providers, and third-party administrators to resolve claim disputes and questions.
• Ensure accurate data entry and documentation in claims processing systems.
• Analyze claim trends and identify potential fraud or abuse.
• Stay up to date on changes in healthcare laws, plan policies, and industry best practices.
• Assist with appeals and grievances by gathering relevant documentation and preparing case summaries.
• Collaborate with auditors and compliance teams during claims audits or investigations.

Skills: .

• Technical Skills: Experience with claims processing software, Microsoft Office Suite, and data entry systems.
• Attention to Detail: Ability to review claims for accuracy, completeness, and compliance.
• Communication Skills: Strong verbal and written communication skills for interacting with members, providers, and third-party administrators.
• Analytical Skills: Ability to assess claims, identify discrepancies, and resolve disputes effectively.

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