CLAIMS EXAMINER

Ensures claims are coded and processed correctly and meets production requirements.

Responsibilities

• Compares data on claim with internal policy and other company records to ascertain completeness and validity of claim.
• Adjudicates medical claims, applies coordination of benefits as outlined in plan guidelines, and works with providers to gather necessary documents for final payment determination.
• Ensures all claims are coded properly according to medical, dental, and vision plan benefits.
• Examines Summary Plan Document, claim adjustors' reports, or similar claims/precedents to determine extent of coverage and liability.
• Maintains high quality standards to avoid incorrect claim payments.
• Maintains productivity standards set by management.
• Refers questionable claims to Claim Examiner II for review and processing.
• Researches and resolves paid and denied claims escalations from internal sources and/or TIPS ticketing system.
• Processes and releases claims for adjudication and payment within 3-5 days of receipt using the claims queue manager.
• Performs other duties and responsibilities as assigned by management.

Requirements

• Associate's degree (A.A.) or equivalent from a two-year college or technical school.
• 3-5 years of employee benefits industry/claims examiner experience or equivalent combination of education and experience.
• Experience processing medical claims for an insurance company or third-party administrator.
• Highly proficient in ICD-10, CPT, and HCPCS codes.
• Valid, class C driver’s license in the state of employment with no adverse driving record.

Skills

• Excellent written and verbal communication skills.
• Strong analytical and problem-solving skills.
• Dependable with excellent attendance and punctuality.
• Fast and accurate data entry operations.
• Ability to adapt to changing demands of the position and company.
• Strong computer skills, including Word, Excel, and Outlook.
• Ability to read, interpret, and write documents such as safety rules, operating instructions, and procedure manuals.
• Ability to write routine reports, meeting notes, project documentation, and correspondence.
• Ability to speak effectively before customers or employees and resolve customer service issues within guidelines.
• Basic mathematical skills, including addition, subtraction, multiplication, division, and computation of rates, ratios, and percentages.
• Ability to apply common sense understanding to carry out instructions in written, oral, or diagram form.
• Ability to handle problems involving several concrete variables in standardized or non-standardized situations.

Physical Demands

• Regularly required to sit for extended periods in front of a computer.
• Frequently required to reach with hands and arms and talk or hear.
• Occasionally required to stand, walk, and use hands to finger, handle, or feel.
• May frequently lift and/or move up to 10 pounds.
• Specific vision abilities required include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus.
• Position requires working in the office.

Work Environment

• The noise level in the work environment is usually moderate.