Claims Examiner

Summary/Objective:

This position is responsible for analyzing and processing facility, ancillary and physician claims, checking them for validity. Medical claims examiner reviews claims for various items, including appropriate billing practices, and coverage based on the Health and Welfare Guidelines. The Examiner must possess knowledge of medical terms, such as Current Procedural Terminology (CPT), Health Care Procedure Coding Systems (HCPCS) and International Classification of Diseases (ICD-10) to review the claim accurately.

Essential Functions

• Validate information on all medical claims from members and providers seeking payment from their benefits.
• Request required information from both internal and external sources to establish whether the claim is complete and valid.
• Ability to examine different types of claims (ie: electronic, paper, dental, member reimbursements, etc.)
• Exercise prudent judgement to determine when claims require repricing, case management review, or additional information.
• Communicate effectively with Leadership, cross departments, members, providers, and vendors to expediently handle claim issues.
• Follow appropriate HIPAA guidelines related to patient privacy and confidentiality.
• Attend and participate in Claims Department meetings for training purposes.
• Meet and maintain production and quality standards.
• Ability to navigate through multiple vendor portals.
• Test and verify new or enhanced system applications, if necessary.
• Examine a claim using plan document, schedule of benefits, supporting documentation, Knowledge Articles, and other resources to make reasonable decisions regarding proper payment of claims.

· Identify order of payment for coordination of benefits with other insurance companies.

· Identify eligibility issues.

• Identify billing trends and/or industry changes to notify management.
• Collaborate with other team members, sharing knowledge and processing techniques.
• Create and maintain Knowledge articles.
• Other duties as assigned.

Education and Experience

· High School diploma or G.E.D. Certificate.

Specialized skills/technical knowledge required:

· Understand Plan eligibility and payment rules including excluded and included covered benefits.

· Must have general medical terminology and anatomy knowledge.

· Must be able to handle a high quality and production environment.

· Be able to communicate effectively and professionally in all areas of communication.

· Knowledge of healthcare coding systems and methodologies such as CPT, ICD-10 and DRG.

· Must have strong organizational, and problem-solving skills.

· Must be a team player.

· Proficient in Microsoft Office applications.

· Ability to handle multiple tasks in a fast-paced environment.

· Ability to read and interpret medical records preferred, but not mandatory.

· Ability to work independently as well as, with others to meet deadlines and resolve any outstanding processing issues.

· Must be detailed oriented.

· Must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier, and telephone.

· Knowledge of ISSI or similar claim processing systems.

· Knowledgeable of Salesforce is preferred, but not necessary.