Determination Adjudicator at Zion Healthshare – St George, Utah

Zion HealthShare is a nonprofit medical cost-sharing program that provides an organized structure for members to contribute toward each other’s medical costs. We offer individuals and organizations across the country an affordable alternative to insurance; this provides peace of mind. Our goal is to be America’s leading HealthShare. We strive to meet our members’ needs on a personal level by following our core values: innovation, excellence, transparency, and community.

Everything we do for our members is to ensure they feel respected and to let them know we truly care about their needs. Our mission is to change the healthcare industry by connecting like-minded individuals to an innovative and affordable medical cost-sharing community.

About the role

The Determinations Adjudicator plays a critical role in ensuring that all submitted medical sharing requests align with the member guidelines established by the Zion HealthShare community. This position requires a detail-oriented and policy-driven individual who can assess complex medical documentation and make fair, consistent determinations regarding eligibility for sharing.

What you'll do

• Review medical documentation and supporting records submitted with each sharing request to ensure they are complete, accurate, and in compliance with member guidelines.
• Apply a working knowledge of the healthcare system, various medical conditions, and commonly recommended or evidence-based treatments to evaluate the appropriateness of care.
• Use sound clinical judgment and understanding of treatment timelines, diagnostics, and procedures to assess whether services meet eligibility criteria.
• Collaborate with internal teams to obtain clarification or additional information when needed.
• Document all determinations clearly and consistently, including justification for eligibility for sharing or not sharing, or requests for more information.
• Stay informed of updates to member guidelines and changes in standard treatment practices across a wide range of medical specialties.
• Maintain strict confidentiality and compliance with HIPAA and organizational policies when handling member health information.
• Continuously strive to exceed member expectations ensuring a high level of member satisfaction.
• Provide recommendations to the Zion HealthShare Member Guidelines as needed.

Qualifications

• Minimum requirement - Applicant must poses one or more of the following:
• • Active Utah or National Medical Assistant (MA) license
  • Certified Professional Coder (CPC) (AAPC)
  • Certified Coding Associate (CCA) (AHIMA)
  • Certified Billing and Coding Specialist (CBCS) (NHA)
• Extensive knowledge of the healthcare system, medical terminology, and standard treatments for a variety of acute and chronic conditions.
• Experience reviewing medical records or adjudicating healthcare claims preferred.
• Familiarity with Customer Relationship Management (CRM) systems; ability to navigate and utilize CRM tools to track case progress and communications.
• Strong analytical and critical thinking skills with the ability to interpret medical information in the context of organizational guidelines.
• Excellent written and verbal communication skills.
• High attention to detail and the ability to make consistent, unbiased decisions.
• Prior experience in healthcare, medical review, case management, or a health-sharing organization is strongly preferred.
• Certification or formal training in medical billing/coding, nursing, or a related healthcare field is a plus.
• Professional level of verbal and written communication
• Thrive in a fast-paced work environment
• Proficient in Microsoft Suite
• Experience working with 2 monitors, and multiple programs running at the same time
• Sit for up to 8 hours a day and look at dual computer screens
• Type on a keyboard at a minimum of 45 WPM

Experience preferred

• Additional pay incentive available for fluent Spanish-speaking employees

Benefits

• 13 paid holidays, including your birthday and personal preference day, plus paid time off to balance work and life.
• Healthcare package including Medical, Dental, Vision, HSA with a company match, Supplemental Insurance like Life and Short-Term Disability, Health Share and a free DPC Memberships.
• Invest in your future with a 401k plan backed by a solid 4% match from us.
• Bi-weekly paychecks.
• Enjoy the perk of free snacks and regular lunches available onsite.
• Build strong connections with colleagues at our frequent, fun team-building events.