About This Role
This role involves processing medical claims to ensure accurate and timely payment resolution. The company is hiring for both a Claims Examiner and a Senior Claims Examiner, with the senior position handling more complex claims, adjustments, and training responsibilities.
Responsibilities
- Adjudicate 150 claims per normal workday
- Maintain 98% statistical accuracy and 98% financial accuracy
- Resolve pending claim issues and correct Department of Defense (DoD) error reports as needed
- Respond promptly to Customer Service and Provider Relations inquiries
- Communicate with other departments to support efficient workflows
- Follow HIPAA requirements and protect confidential patient information
- Perform other assigned claims-related duties
- Process CMS-1500 and CMS-1450/UB-04 claims from facilities, physicians, home health agencies, durable medical equipment providers, and laboratories
- Research and resolve payment discrepancies, overpayments, and underpayments
- Process adjustments, provider refunds, reconsiderations, direct member reimbursements, and overpayment recoveries
- Execute batch claim adjudication and escalate issues as appropriate
- Support system testing, upgrades, conversions, and process improvements
- Help train new and existing staff on procedures and policy updates
- Identify claims trends and workflow gaps and assist with updating procedures
- Respond to internal and external inquiries regarding claim issues
- Meet established productivity and quality standards
Requirements
- High school diploma
- Ability to meet the stated claims processing productivity and accuracy standards
- Associate
-s degree or equivalent job-related experience
- At least 3 years of medical claims processing experience in healthcare
- Knowledge of medical terminology, CPT, HCPCS, ICD-10, revenue codes, CMS-1500 and CMS-1450/UB-04 forms, and reimbursement methodologies
- Proficiency in Microsoft Office, including Excel, Word, PowerPoint, and Outlook, plus spreadsheet and database skills
- Strong communication, organization, attention to detail, and problem-solving skills
- Ability to prioritize work and meet deadlines
- No licenses or certifications required
Nice to have:
- Managed care, Medicare, Medicare Advantage, Health Exchange, and TRICARE experience
Benefits
- Dental insurance
- Health insurance
- Vision insurance
Important Details
