Claims Examiner

Key Responsibilities

• Apply medical policy, contractual provisions, and operational procedures to ensure accurate adjudication and/or adjustment of Group Health and Workers' Compensation Hospital and Medical claims.
• Resolve claim holds, review history records, and determine benefit eligibility for services rendered.
• Research and document all pertinent information on claims requiring adjudication.
• Respond to inquiries related to specific claim issues via email, chat, or verbal communication.
• Perform non-standard claim data entry, including detailed claim notation and documentation.
• Complete assigned projects and tasks within established deadlines.
• Assist Customer Service, Casualty, Medical Management, and Management teams by providing support in resolving claims and responding to questions and concerns.
• Maintain compliance with production and quality standards established for the role.
• Escalate issues to the Manager or Supervisor when appropriate.
• Perform other related duties as assigned to support departmental goals.

Required Qualifications

• A High School Diploma or GED is required.
• One to three years of medical or hospital claims processing experience are required.
• A strong understanding of medical terminology, CPT/HCPCS and ICD coding, and benefits administration are necessary.
• The ability to interpret medical policies, provider contracts, and plan documents is essential.
• Excellent analytical and problem-solving skills, with the ability to identify discrepancies and resolve complex claim issues, are required.
• Proficiency with claims processing systems, data entry platforms, and standard office software (e.g., Microsoft Office) is necessary.
• Strong written and verbal communication skills for interacting with internal teams and responding to inquiries are required.
• The ability to manage multiple tasks and meet performance standards for speed and accuracy is necessary.