Job Description:
Claims Examiner will be responsible for adjudicating complex claims, manually and/or automatically price claims accurately, and identify billing issues.
Responsibilities include, but not limited to:
- Analyze, research, and process and/or adjust claims with accurate use of procedures and ICD-10 codes under respective provider and member benefits based on:
- Contractual agreement
- Health Plan division of financial responsibility
- Applicable regulatory legislature
- Claims processing guidelines
- Client group’s and company’s policies and procedures
- Review and process facility (UB-04) and professional (CMS-1500) claims.
- Process Medicare member claims based on DMHC and DHS regulatory legislature
- Respond and resolve providers’ and health plans’ inquires in a timely manner
- Review services for appropriate charges and apply authorization
- Monitor aging claims with reports to maintain timeliness
- Maintain quality and productivity standards
- Participate in special projects
- Works closely with Supervisor and reports any issues
Qualifications:
- At least a high school diploma
- Applicable healthcare claims adjudication experience within a managed care industry is a plus
- Familiar with ICD-10, HCPCS, CPT coding, APC, ASC, and DRG pricing
- Familiar with facility and professional claim billing practices
- Must have good written and communication skills.
- Must be able to follow guidelines, multi-task, and work comfortably within a team-oriented environment.
- Computer literacy required, including proficient use of Microsoft Word, Excel, and Outlook. Knowledge in EZ-CAP 6X is a plus.
- Familiar with SSRS is a plus.
- Typing skills of at least 40 wpm.
