About This Role
This senior examiner position provides support for claims examination activities. The core of the role involves evaluating the adjudication of claims to identify incorrect coding, abuse, fraudulent billing practices, waste, overpayments, and processing errors. It suits a professional with strong analytical and organizational skills in a claims environment.
Responsibilities
- Evaluate the adjudication of claims using standard principles and state-specific regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and claims processing errors
- Manage a caseload of claims, procuring all medical records and statements that support the claim
- Make recommendations for further investigation and/or resolution of claims
- Oversee the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication, and recommend solutions to resolve issues
- Identify and recommend solutions for error issues as it relates to pre-payment of claims
- Monitor the medical treatment of claimants; keep meticulous notes and records for each claim
- Manage a caseload of various types of complex claims, procuring all medical records and statements that support the claim
- Meet state and federal regulatory compliance regulations on turnaround times and claims payment for multiple lines of business (LOBs)
- Meet department quality and production standards
- Support all claims department initiatives to improve overall efficiency
- Complete claims projects as assigned
Requirements
- At least 2 years of experience in claims and/or customer service experience in a clerical role, preferably in a managed care setting, or equivalent combination of relevant education and experience
- Research and data entry skills
- Organizational skills and attention to detail
- Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines
- Customer service experience
- Effective verbal and written communication skills
- Microsoft Office suite and applicable software programs proficiency
Nice to have:
- Health care claims/billing experience
Benefits
- Competitive benefits and compensation package
