Claims Examiner

About the role

Under management direction, responsible for reviewing and processing all types of medical and facility claims from contracting and non-contracting providers and from subscribers and enrollees for payment in an accurate and timely manner. Responsible for applying correct contract benefits, policies and procedures. This position is responsible for claims auditing and payment functions for a Knox-Keene licensed health maintenance organization (HMO).

Essential Duties and Responsibilities

• Resolve system suspended claims for: PCPs, Labs, Radiology, less complicated specialists, Physical Therapy
• Deny inappropriate claims following policy guidelines
• Prepare claims that must be routed to other departments for further review
• Review difficult claims with guidance from Claims Supervisor
• Responsible for identifying billing errors and possible fraudulent claims submissions
• Obtain eligibility verification and other health insurance coverage by Internet or POS
• Responsible for correct manual calculation of benefits when applicable
• Responsible for identifying possible CCS eligible claims for further investigation
• Report overpayment refund requests on SharePoint log
• Maintain productivity and quality in accordance with established guideline
• Perform other job-related duties as required
• Regular predictable attendance
• Adheres to all company policies and procedures relative to employment and job responsibilities

Employment Standards

• High School Diploma from an accredited school or equivalent
• Minimum of one (1) year medical Claims Examiner processing experience

Pay

Pay range shown reflects the full range for this position. Initial offers are typically positioned between the minimum and midpoint, based on qualifications and internal equity.

Minimum: $21.15 Mid-Point: $26.44 Maximum: $31.73