Claims Examiner

About This Role

Caring for self-funded groups by properly applying plan provisions is the core of this role. The Claims Examiner processes medical, dental, and vision claims, answers related questions, and works with other departments to resolve client concerns while maintaining a comprehensive understanding of plan documents.

Responsibilities

• Interpret plan documents
• Review, research, and analyze information to determine eligibility
• Process, deny, pend, or allow claims
• Use thought and reasoning to manage workload that carries an average level of financial risk
• Accurately note the system of all information received
• Forward all records
• Track and return calls and e-mails
• Answer specific plan and claim questions
• Know each team member for each group
• Go over review issues
• Note system when appeals and inquiries are received
• Record all information on appeals and inquiries in the database
• Note system if notified that claim is going to outside review or committee
• Act as a role model in demonstrating the core values in customer service delivery
• Provide timely and thorough follow up with internal and external customers
• Track and return telephone calls/mail to members and groups answering specific plan/claim questions within 24 hours
• Appropriately escalate difficult issues up the chain of command
• Ensure team compliance with service standards
• Serve on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction
• Recognize and alert appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters
• Perform self-quality monitoring in order to develop and execute plans to meet established goals
• Provide ongoing feedback to help optimize quality performance
• Collaborate with others and cross-departmentally to improve or streamline procedures
• Remain current on industry trends and look for new data sources
• Develop new or improve current internal processes to improve quality

Requirements

• High School Diploma or equivalent
• 1+ years' experience in clerical and customer service

Nice to have:

• Associate degree in Medical Billing and Coding or related field
• Claims or Medical Office experience
• Knowledge of medical terminology
• Working knowledge of computers and software including but not limited to Microsoft Office products
• Proficient mathematical, 10-key and typing skills