Claims Examiner

Researches and adjudicates all types of claims to ensure that protocols are followed with regard to provider contracts, member benefit schedules, established guidelines, and departmental policies and procedures.

Essential Functions & Responsibilities

  • Processes & adjudicates the claims for accounts requiring multiple disciples in claims processing.
  • Verifies claim information.
  • Reviews referral information for verification of services rendered.
  • Reviews eligibility for verification of member eligibility at time of service.
  • Enters claims information into the claims adjudication system – when applicable.
  • Validates results of claims after completion of pre-processor, adjudication & claims pricing.
  • Corrects all system edits as a result of the 3 step claims process.
  • Researches, reviews and adjudicates pended claims.
  • Recognizes claims issues/problems, refers them to management and/or appropriate party, and assists in the review and implementation of resolution.
  • Assures that claims are processed in accordance to member benefits, provider contact terms, network protocols, medical authorization and departmental guidelines.
  • Maintains individual productivity reports on claims adjudication.
  • Maintains production and quality standards established by Claims Department Management.
  • Provides back up to the clerical staff, other claims examiners and claims customer service.
  • Some overtime may be required.
  • Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
  • Ability to come to work and work the regular schedule and shift for the position.
  • Compliance with all personnel policies and procedures.
  • Special projects and other duties as assigned by senior management.
  • Perform additional duties and related essential duties as assigned.

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Education and/or Experience

  • Minimum of 5 years experience in a Medical Claims processing environment performing claims adjudication with varying levels of difficulty.
  • Prior claims adjudication experience with HMO, PPO, POS, Commercial, Medicare and Medicaid lines of business.
  • Demonstrated knowledge of ICD-9, ICD-10, CPT-4, HCPCS coding, and medical terminology.
  • High school diploma or equivalent
  • Strong interpersonal communication skills in English. (both written & verbal)
  • Spanish communication skills helpful but not necessary.

Certificates, Licenses, Registrations

  • N/A

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