About This Role
This position is responsible for analyzing and processing facility, ancillary, and physician claims, checking them for validity. The Claims Examiner reviews claims for various items, including appropriate billing practices and coverage based on Health and Welfare Guidelines, and must possess knowledge of medical terms such as Current Procedural Terminology (CPT), Health Care Procedure Coding Systems (HCPCS), and International Classification of Diseases (ICD-10) to review claims accurately.
Responsibilities
- Validate information on all medical claims from members and providers seeking payment from their benefits
- Request required information from both internal and external sources to establish whether the claim is complete and valid
- Examine different types of claims (e.g., electronic, paper, dental, member reimbursements)
- Exercise prudent judgment to determine when claims require repricing, case management review, or additional information
- Communicate effectively with Leadership, cross-departments, members, providers, and vendors to expediently handle claim issues
- Follow appropriate HIPAA guidelines related to patient privacy and confidentiality
- Attend and participate in Claims Department meetings for training purposes
- Meet and maintain production and quality standards
- Navigate through multiple vendor portals
- Test and verify new or enhanced system applications, if necessary
- Examine a claim using plan document, schedule of benefits, supporting documentation, Knowledge Articles, and other resources to make reasonable decisions regarding proper payment of claims
- Identify order of payment for coordination of benefits with other insurance companies
- Identify eligibility issues
- Identify billing trends and/or industry changes to notify management
- Collaborate with other team members, sharing knowledge and processing techniques
- Create and maintain Knowledge articles
- Other duties as assigned
Requirements
- High School diploma or G.E.D. Certificate
- Understand Plan eligibility and payment rules including excluded and included covered benefits
- General medical terminology and anatomy knowledge
- Ability to handle a high quality and production environment
- Communicate effectively and professionally in all areas of communication
- Knowledge of healthcare coding systems and methodologies such as CPT, ICD-10 and DRG
- Strong organizational and problem-solving skills
- Team player
- Proficient in Microsoft Office applications
- Ability to handle multiple tasks in a fast-paced environment