Claims Examiner 1

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.

Minimum Qualifications

• Required and/or Preferred Education: 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: Must have working-level 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.
• 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.