Claims Examiner – Health Plan
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 5-6 months, or longer! ***
Claims Examiner Job Summary:
Claims Examiner Background:
- Analyzes and processes claims, and is responsible for following regulatory and internal guidelines in conjunction with policies and procedures as they apply to claims adjudication.
- Responsible to adjudicate more complex claims, requiring additional research or problem solving.
- Responsible for accurate and timely adjudication of claims according to guidelines.
- Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue, ICD-9 and ICD-10 codes, under the correct provider and member benefits, i.e. co-payments, deductibles, etc.
- Claims processing based upon contractual agreements, involving the use of established payment methodologies, Division of Financial Responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures.
- Alerts manager or supervisor of issues that impact production and quality, i.e. incorrect database configurations, non-compliant claims, etc.
- Responds to incoming calls from providers of service in a timely and courteous manner.
- Resolves issues as presented or as referred by the examiners.
- Process claims based on compliance regulation and timeframes.
- Process both professional (CMS-1500) and facility (UB-04) claim types.
- Maintain quality and productivity standards as set by management.
- Resolve provider or physician group (network) claims inquiries and apply resolution in a timely fashion.
- Responds to questions from examiners. Explains processing guidelines and internal processes when needed.
- Review services for appropriateness of charges and apply authorization guidelines during claims processing.
- Prepare written requests to providers; follow up and handle completion of claim for returned correspondence.
- Requires an education level of at least a high school diploma or GED.
- Prefer, but does not require, a Certified Health Data Analyst (CHDA) or similar.
- At least 1-2 years experience processing on-line claims in a managed care environment.
- Around 4-5 years in member services or health data analysis experience, preferably in managed care environment.
- Knowledge of health care delivery system, Medicaid/Medicare, related state programs, and dual eligibility programs required.
- Strong working knowledge of concepts, practices, and procedures related to managed care / practice management.
- Established experience with database management system.
- Basic familiarity with Medical terminology is required.
- Computer skills to include Microsoft Word, Excel and basic data entry, including the ability to learn new and complex computer system applications.