Claims Examiner

About This Role

The Claims Examiner adjudicates medical claims and responds to inquiries, ensuring accurate and timely processing. This role suits a customer-focused, energetic, and detail-oriented individual who can work both independently and as part of a team.

Responsibilities

• Process professional and facility medical services claims by reviewing and inputting data into the claims payment system using standard policies, procedures, and guidelines
• Meet a quality/accuracy standard of 95% and production standards of 100-125 claims/day
• Forward claims to appropriate departments for Medical Review, Eligibility, etc.
• Verify coverage and interpret contracts
• Pursue and follow up on open and pended claims promptly and independently
• Research and investigate claims with multiple coverage and complexity to determine if the claim is payable in accordance with various policy provisions
• If payable, determine eligible payee(s) and payment amounts
• If not payable, develop a detailed letter of explanation based on policy provisions and claim documents
• Maintain focus and stay on task with minimal supervision
• Participate in and practice principles of continuous quality improvement

Requirements

• High school diploma required; college degree preferred
• Minimum 1-3 years of medical claims processing experience in Managed Care
• Strong experience and knowledge of medical claims, Medicare/Medicaid guidelines, ICD-10, HCPCS / CPT Coding, HCFA 1500’s & UB04’s
• Strong communication, analytical, organizational, and problem-solving skills
• Excellent time management skills
• Proficient with Microsoft applications (Word, Excel, Outlook) and database systems
• Ability to read and interpret documents such as processing and procedure manuals, medical terminology, and claims rules and regulations to appropriately develop the claim
• Ability to write routine, professional correspondence using correct grammar and spelling
• Ability to identify and define problems; collect data; establish facts and draw valid conclusions
• Must be able to consistently interact with customers in a professional and respectful manner

Nice to have:

• EzCap Claims payment systems knowledge

Important Details

• Work format: full-time in-office presence for the first 60 days of employment; hybrid schedule available after initial training period

About the Company

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing Whole-Person care to Senior and Medicaid populations through advanced value-based models. Its provider network is comprised of more than 3,500 providers including Primary Care, Specialty, Hospital System, and ancillary provider partnerships. The company has operated in the Arizona market for more than 14 years and is based in Chandler, Arizona.