Claims Examiner

JOB SUMMARY

The Claims Examiner is responsible for claims processing, research and adjudication to correctly apply benefit determinations on routine medical claims (CMS 1500 and UB04) and Rx claims in accordance with claims processing guidelines.

ESSENTIAL FUNCTIONS OF THE ROLE

Processes and adjusts routine professional, facility and Rx claims according to claims processing guidelines. Pends claims as directed by departmental policies and procedures, follows up for resolution, and processes pended claims immediately following a benefit/payment determination. Maintains confidentiality rules in compliance with HIPPA guidelines.

Works claims inventory from assigned queues to ensure all claims are processed within established turnaround time as directed by department policies and procedures. Focuses on achieving departmental and organizations objectives.

Reviews all output reports to ensure accurate benefit and rider determinations. Completes reports to ensure prompt payment of claims.

Identifies and reviews systematic or procedural problems with management for timely follow-up and correction. Consistently meets/exceeds productivity standards and accuracy standards for payment, procedural and financial.

Performs follow-up and takes all necessary actions required to resolve errors and findings assessed by the Quality Review Team.

KEY SUCCESS FACTORS

Able to understand and apply basic policies, practices, and procedures.

Good written and verbal communication skills with an emphasis on confidentiality, tact and diplomacy.

Good organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneously.

Intermediate proficiency and experience using Microsoft Office (Excel, Access, PowerPoint and Word).

Superlative customer service skills.

May be required to work in excess of regular scheduled hours.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

- EDUCATION - H.S. Diploma/GED Equivalent

- EXPERIENCE - Less than 1 Year of Experience