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Claims Examiner

Responsible for the review and processing of regular claims using established claim standards and departmental policies and procedures ensuring that the work is performed accurately and delivered to meet set objectives.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Accurately evaluates and adjudicates complex claims in a timely manner and according to set standards. Regular claims include but not limited to professional claims, Lab, DME, ambulance, as well as outpatient facility UB claims.
Able to review and match authorization for the service.
Assists in optimizing work flows, troubleshooting and problem solving to claims.
Develop and maintains any/all necessary documentation for claims adjudication
Identifies and resolves provider billing issues, including provider/vendor communication in writing.
Ensures accurate interpretation of government laws, rules and any regulations, as well as internal organization guidelines.
Research, accesses and utilizes on-line reference for claim issues and resolution.
Assists with completion of claims audits conducted on TPA.
Accepts and performs other duties as assigned, including frequent special projects.

QUALIFICATIONS

Education
Proficient English (verbal and writing) is required.
College preferred.
Insurance claims and Healthcare administration background strongly preferred.
Strong computer skills required. Any programming / database skill is highly preferred.
Prior Related Experience
2 or more years’ experience in health care with complex claims
Medicaid and Medicare experience preferred

Time:  Full time
Salary:  Salary
Category:  Finance

Updated: 10/26/2021 4:40:20 PM