Insurance Claims Examiner II

Level II

Level III

1

Analyzes and processes minimum of 200 claims daily to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims

Analyzes and processes minimum of 400 claims to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims

2

Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations

Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations

3

Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments

Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments

4

Assists with other research and development projects as directed by Management; obtains and maintains necessary certification for Health Insurance Marketplace CAC

Provides training and guidance through expert knowledge of claims administration and adjudication to Insurance Department staff; responsible for the timely response to formal appeals from members, employees, clients and providers

5

Reviews, resolves and/or escalates Level 2 claims appeals; releases claims up to the designated draft authority for Level 2 Claims Examiner

Works with the Customer Service Coordinator to manage and provide direction to the utilization review and case management vendor; identifies and manages claims with potential subrogated recovery

6

Ensures that claims adjudication complies with all FCPID standards and protocols; reviews claims for possible abuses and/or fraud and bring to the attention of management

Oversees the repricing processes to ensure the integrity of the product; investigates claims referred by staff for possible abuse and fraud

Level II

Level III

1

High School Diploma or GED

High School Diploma or GED

2

Five (5) years of experience in medical claims processing

Five (5) years of experience in medical claims processing

3

Three (3) years in customer service

Three (3) years in customer service

4

Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards

Two (2) years in a lead or supervisory capacity

5

Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology

Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards

6

Knowledge of insurance principles and/or procedures

Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology

7

Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment

Knowledge of insurance principles and/or procedures

8

Must successfully pass all applicable background checks and drug screens

Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment

9

Must successfully pass all applicable background checks and drug screens