Claims Examiner

About This Role

Examining and processing health insurance claims accurately and on time is the main focus of this role, ensuring compliance with department standards. The position involves reviewing claims based on various guidelines and identifying complex issues for resolution.

Responsibilities

• Adjudicate and enter claims for all lines of business according to benefit plan designs and regulatory standards
• Review claims based on coverage benefits, coding guidelines, medical review determination, billing discrepancies, and cost containment measures
• Identify third-party or coordination of benefits issues and notify designated claims department Coordination of Benefits (COB) personnel for timely review and resolution
• Understand and manually calculate all types of claims pricing (Medicaid, Medicare, and UCR - Usual, Customary and Reasonable, etc.)
• Identify inappropriate or questionable claims and refer to Claims Analysts for review
• Research all complex claims, disputes, and appeals thoroughly to make accurate payment decisions in a timely manner with input from the Claims Analysts for quality assurance
• Process claim corrections and COB updates via interdepartmental customer relationship management process
• Generate and review production reports daily for quality and training purposes
• Maintain quantity/quality department goals regarding the number of claims entered and accuracy percentages
• Complete side-by-side and peer training as necessary for educational opportunities
• Assist with projects and clerical support as needed

Requirements

• High School or General Education Diploma (GED) and two to four years related experience and/or training; or equivalent combination of education and experience
• Knowledge of word processing software, spreadsheet software, internet software, and Epic software
• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals
• Ability to write routine reports and correspondence
• Verbal and written communication skills
• Ability to perform arithmetic calculations
• Ability to work independently
• Ability to meet deadlines
• Ability to maintain a good rapport and cooperative working relationship with the team
• Ability to speak effectively before groups of customers or employees of organization
• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume
• Ability to apply concepts of basic algebra and geometry
• Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form