Claims HMO - Claims Examiner 140-1044
- Not specified
Posted 2 months ago
About the role
JOB SUMMARY:
The Claims Examiner is responsible for examining claims that require review prior to being adjudicated. 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:
The Claims Examiner is responsible for examining claims that require review prior to being adjudicated. 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:
- Examining and adjudicating claims that have pended for review utilizing resources, tools, knowledge and decision-making in determining appropriate actions.
- Identify claims requiring additional resources and route to the team lead, supervisor or other departments as needed.
- Enter claims information using the processing software to compute payments, allowable amounts, limitations, exclusions and denials.
- Identify and communicate trends or problems identified during adjudication process.
- Contribute to the creation of a pleasant working environment with peers and other departments.
- Assist in investigating and solving claims that require additional research.
- Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.
- Perform other job-related duties as assigned.
- Self-motivated and able to work with minimal direction.
- Ability to read and understand claims processing manuals, medical terminology, CPT codes, and perform basic processing procedures.
- Ability to read and understand health benefit booklets.
- Demonstrated learning agility.
- Successful completion of Health Care Sanctions background check.
- Knowledge in the contracted managed care plan terms and rates.
- General understanding of unbundling methods, COB, and other over-billing methodologies.
- Must have high attention to detail.
- Proficient in Microsoft applications.
- Ability to perform basic mathematical calculations.
- Possess strong oral and written communication skills.
- High School Diploma or Equivalent required.
- Two years related work experience in claims processing, claims data entry or medical billing OR medical related education to meet minimum two years required.