The Claims Examiner reports to the Supervisor of Claims. The Claims Examiner is responsible for reviewing and adjudicating claims based on provider and health plan contractual agreements and claims processing guidelines.
* Complies with all internal processes and procedures to ensure activities are handled in accordance with departmental and company policies and procedures. * Review, research, analyze, and process complex healthcare claims by navigating multiple computer systems and platforms and accurately capturing the data/information for processing (e.g. verify pricing, prior authorizations, applicable benefits). * Escalates claim and/or system issues to Team Lead or Supervisor. * Creates and supports a professional environment which fosters teamwork, cooperation, respect and diversity. * Meet department quality and production requirements This position is required to meet and maintain performance goals established for the position in the areas of quality and production. * Process claims for multiple Lines of Business as requested by management. * Understands processing rules for multiple lines of business and supports other lines of business as needed to meet business needs.
* Minimum of 1 to 3 years's prior claims/billing experience preferred. * High School Diploma or GED required. * Knowledge of medical terminology preferred. * Knowledge of Medical Billing/CPT and ICD 9 coding or related experience required. * Healthcare or managed care experience preferred. * Minimum 35 wpm typing preferred. * Demonstrated ability in using computer and Windows PC applications, which includes strong keyboard and navigation skills and leaning new computer programs. * Ability to research and investigate information using multiple sources and documented guidelines * The Operations Center hours are 8:30 a.m. to 5:00 p.m. Monday through Friday. The Claims Examiners work a set eight (8) hour shift within those operational hours. * Expected start date will be 9/23/2019.