Claims Examiner 1

Position Purpose:

Under the direction of the Claims Manager, this position is responsible for ensuring accurate and timely data entry and processing of all HMO, PPO, TPA and dental claims within departmental standards and procedures. This position is also responsible for the research of members and providers to ensure accurate and timely payment.

Nature and Scope:

This position is responsible for:

• Ensuring claims are keyed and accurately adjudicated according to Health Plan, Departmental, State and Federal regulations and procedures.
• Ensuring the appropriate member benefits and provider contracts have been identified and releasing claims for payment without second review once a benefit determination has been made.
• Researching claims as needed in order to adjudicate timely and accurately.
• Processing basic claims to an adjudicated status.
• Completing projects as assigned by the Claims Manager or other health plan management.
• Participating in quality improvement and change management procedures and processes.

The Incumbent must have the ability and desire to work in an environment with quality and production goals.

The Incumbent must comply with all Company HIPAA policies and procedures.

This position does not provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications: Requirements - Required and/or Preferred

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English. A minimum of a two year degree in a related field is preferred.

Experience:

Six months experience in data entry required. Experience with medical claims entry/research or related field preferred. Knowledge of ICD-9/10, CPT coding, UB-92 Revenue coding, and ADA coding as well as familiarity with universal claim forms such CMS 1500 and UB-92 is preferred. Keyboard knowledge and expertise, including on-line processes is required. Medical terminology experience is preferred.

License(s):

None.

Certification(s):

None.

Computer / Typing:

Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.