Claims Examiner

About This Role

This contract role involves reviewing, analyzing, researching, and resolving complex medical claims in accordance with processing guidelines and federal regulations. The Claims Examiner Senior works with various departments to ensure the validation and quality assurance of claims processing, focusing on medical claims and related projects.

Responsibilities

• Analyze medical claim information and take appropriate action for payment resolution in accordance with policies, procedures, guidelines, and federal regulations
• Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc.
• Work claim projects resulting from overpayments or underpayments related to manual processing errors, benefit updates, and/or contract, fee schedule changes
• Process provider refunds, reconsiderations, and direct member reimbursements
• Process medical claim adjustments, recovery of claim overpayments, and execution of claim batch adjudication
• Solve moderately complex claims and escalate issues to the Claims Team Lead, Supervisor or Manager
• Assist with database improvements and testing for system upgrades, conversions, or implementation of new processes
• Serve as a resource to assist with training new associates, retraining current associates on new/updated desktops/policies and report staff progress, deficiencies, and training needs to management
• Set high standards of performance and promote teamwork to achieve established team goals, while maintaining a positive, professional attitude
• Contact and respond to internal and external customers for resolution on claim issues
• Assist claims leadership to identify claim trends, gaps in workflow and create/update desktops and policies and procedures
• Collaborate with and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate completion of tasks/goals
• Organize and prioritize work to meet deadlines
• Consistently meet established productivity and quality standards
• Perform other duties as assigned by management to support claims functions, which are focused on achieving both departmental and organizational objectives

Requirements

• Associate's degree or equivalent job-related experience
• Minimum of 3 years' experience processing medical claims in the healthcare industry
• Knowledgeable about medical terminology, CPT, HCPCS, ICD-10, Revenue Codes, CMS-1500 and CMS-1450/UB-04 claim forms and reimbursement methodologies
• Excellent written, verbal, organizational and interpersonal communication skills
• Proficient in Microsoft Office, Power Point, Excel, Word, Outlook, spreadsheet, and database skills
• Good judgment, initiative, and problem-solving abilities
• Attention to detail is critical to ensure timely and accurate processing of claims

Nice to have:

• Prior experience working with managed care, Medicare, Medicare Advantage, Health Exchange, and TRICARE

Important Details

• Schedule: 5 Days - 8 Hours
• Contract: 3 Months

About the Company

Sigma Inc. is currently looking for a Claims Examiner.