Claims HMO - Recalculation Examiner 140-1036

JOB SUMMARY:The Recalculation Examiner is responsible for researching and reprocessing claims that were previously adjudicated and need to be reconsidered for all lines of business. The examiner will use their resources, knowledge and decision-making acumen to determine the appropriate actions to pay, deny or adjust the claim. Examiners are expected to meet performance expectations in accuracy and efficiency.KEY RESPONSIBILITIES:

Researches and reprocesses claims. Includes working with various internal departments including customer service, pricing, provider services, medical management, enrollment, grievance and appeals and configuration departments.Researches corrected claims received by the processing teams which are submitted by providers. Verifies the validity of the corrected claim submission and make necessary changes. Redirects any claims necessary back to processing staff to finalize.Performs clerical duties associated with the processing and completion of inquiries including first level appeal letters to the provider, requests for the loading of information for providers, members or authorizations.Researches and responds to first level inquiry appeals received via paper mail.Determines amounts of overpayments and completes necessary paperwork to request refunds.Maintain inventory tracking log, performs regular follow-up of claims routed to other areas.Interfaces with various departments to reach a resolution on claim corrections, research/re-adjudication projects and potential system issues.Identify and communicate trends or problems identified during adjudication process.Accurately resolves most unique problems or situations without supervisor involvement.Contribute to the creation of a pleasant working environment with peers and other departments.Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.Perform other duties as assigned.

QUALIFICATIONS:

Self-motivated and able to work with minimal direction.Ability to read and understand claims processing manuals, medical terminology, CPT codes and perform claims processing procedures.Knowledge of claims processing manuals and health benefit booklets.Knowledge in the contracted managed care plan terms and rates for multiple lines of business.Successful completion of Health Care Sanctions background check.Proficient in Microsoft applications.Ability to perform basic mathematical calculations.Demonstrated learning agility.Knowledge of Network Authorization requirements.Highly attentive to detail.Possess strong oral and written communication skills.

• Ability to organize time effectively and set priorities to meet deadlines.

EDUCATION/EXPERIENCE:

High school diploma or equivalent required.Three years related work experience in claims processing, data entry or medical billing. One year of claims processing experience within CommunityCare or another healthcare environment is required.