Senior Claims Examiner (50714)

Job Description Summary

The Senior Claims Examiner will process large dollar/complex health care claims, adjustments and contracts that require higher degree of accuracy. This incumbent will thoroughly review, analyze, and research complex health care claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. They will assist in resolving escalated issues including making and answering phone calls to providers/billing offices when necessary based on team guidelines. The Senior Claims Examiner will work on special projects related to provider and plan documents, system upgrades, implementing initiatives to improve claims processing, and turnaround times. They will mentor other team members and lead aspects of training functions and Subject matter expert in a variety of knowledge sets and process improvement activities.

Duties And Responsibilities

Claims Processing & Quality Assurance

• Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, Blue Card, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), FSA, foreign claims, outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, and Medicare Secondary Payer (MSP) by calculating benefit due to approve or deny, based on SPD.

• Research written and/or verbal queries from providers/members/internal departments to determine appropriate action on claim and process corrections as required.

• Analyze patient and medical records to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly.

• Examine claim files for accuracy and make necessary adjustments and corrections: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation, perform complete file reviews when appropriate.

• Review and release High dollar claim or other complex claims.

• Compile records necessary for Enhanced Claim Review (ECR)

• Research through all vendor portals, including but not limited to Valenz, Occunet, Anthem.

• Research, resolve and respond to all correspondence and internal and escalated communication (Ops Connect) related to electronic and paper claims as assigned.

• Review reports and research pended claims to ensure timely adjudication within accepted corporate cycle times. Reports include, but are not limited to, daily and pend reports, weekly cumulative pending, and other special reports as received from customer.

• Assist leadership team improve turnaround times, processes, or staff training identifying errors through data analysis and auditing, and working with various teams to ensure those errors are corrected in both the short and long term

• Ensure legal compliance by following company policies, procedures, guidelines, as well as State and Federal insurance regulations. Assistant Legal Department with Member/Provider appeals/disputes.

• Resolve benefit and eligibility issues that require detailed knowledge, support customers within the claims processing Company and ERISA guidelines.

• Meet and maintain individual and department productivity and quality standards.

• Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation. Utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.

Process Improvement & Innovation

• Perform regulatory operations research to support guideline/SOP/workflow development, provide accurate analysis, documentation, and recommendations for improvements.
• Examine a problem, a set of data or text and considers multiple sides of an issue, weighs consequences before making a final decision.
• Partner with peers and external departments to document, analyze and implement functional requirements, identify gaps and alternative approaches to resolve problems.
• Resolve and alert supervisor of compliance problems and potential higher risk compliance issues
• Act as a Subject Matter Expert (SME) for purposes of training, claims determinations, resource for IT Department for testing new processes and special projects, mentorship, coaching, and Company representative.
• Initiate and execute Work Instructions to enhance claim documentation.

Other

• Utilize all capabilities to satisfy one mission - to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
• Maintain internet speed of 40MB download and 10MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g. smoke detector, fire extinguisher, first aid kit).
• All other duties as assigned.

Qualifications

• High school education or equivalent and seven (7 to ten (10) years of experience as a health claims xaminer or comparable industry experience, preferred.
• Extensive knowledgein medical and dental claim processing, principles, and procedures.
• Advance level of claims processing experience and understanding of medical, dental, FSA, HRA, transplant, coordination of benefits, Medicare, hospital, professional, subrogation, and accident claims, is highly desired.
• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination.
• Proficient in medical terminology, contract and benefit interpretation, UB-04 and HCFA 1500 forms (837/5010 format), medical coding, CPT, ICD10, HCPCS, DRG, National Correct Coding Initiative (NCCI) edits or Medically Unlikely Edits (MUE), with working knowledge of Federal, State and Self-funded insurance plans.
• Excellent verbal, written and interpersonal communications skills to communicate effectively with individuals at all levels of the organization, as well as front line health plan contacts.
• Proficient in 10-key by touch data entry/typing and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications.
• Exceptional time management, multi-task, critical thinking, problem solving skills and ability to work under pressure and adapt to changing environment.
• Working knowledge of Employee Retirement Income Security Act of 1974, (ERISA) claims processing/ adjudication guidelines.
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site.