About This Role
This Claims Examiner I role is responsible for ensuring that claims are correctly coded and processed, meeting all production requirements. The position involves processing claims by comparing data with internal policies and company records to verify completeness and validity.
Responsibilities
- Compare data on claims with internal policy and other company records to ascertain completeness and validity of claim
- Comprehensively understand employee benefits for medical, dental, and vision plans
- Adjudicate medical claims, apply coordination of benefits as outlined in plan guidelines, and work with providers to gather necessary documents to make final payment determination on claims
- Ensure all claims are coded properly
- Examine Summary Plan Document, claim adjustors' reports, or similar claims/precedents to determine extent of coverage and liability
- Maintain high quality standards to avoid paying claims incorrectly
- Maintain productivity standards set by Management
- Refer most questionable claims for investigation to Claims Examiner II for review and processing
- Research and resolve paid and denied claims escalations from internal sources and/or TIPS ticketing system when assigned
- Work from the claims queue manager to process and release claims for adjudication and payment within 3-5 days of receipt
- Perform other duties and responsibilities as assigned by Management
Requirements
- Associate's degree (A.A.) or equivalent from a two-year college or technical school; or 3-5 years of employee benefits industry/claims examiner experience or equivalent combination of education and experience
- Excellent written and verbal communication skills
- Strong analytical and problem-solving skills
- Dependable and maintain excellent attendance and punctuality
- Able to perform data entry operations quickly and accurately
- Ability to grow with changing demands of the position and the company
- Strong computer skills, including Word, Excel, and Outlook
- Experience processing medical claims for an insurance company or third-party administrator
- Highly proficient in ICD-10, CPT, and HCPCS codes
- Ability to read, speak, and write effectively in English
- Ability to interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals
- Ability to write routine reports, meeting notes, project documentation, and correspondence
- Ability to speak effectively before customers or employees of organization
- Ability to effectively address or resolve customer service issues within guidelines of the position
