Claims Examiner I

Job Description Summary

The Claims Examiner I reports to the Supervisor of Claims. They are responsible for reviewing and processing medical, dental, vision, and electronic claims according to state, federal, and health plan regulatory requirements and department guidelines. The role involves thoroughly analyzing claims, verifying pricing, confirming prior authorizations, and processing them for payment. The Claims Examiner I also assists in resolving issues from various internal and external customers.

Qualifications

• High school education or equivalent: minimum three (3) to five (5) years of experience as a Health Claims Examiner or comparable industry experience preferred.
• A minimum of one (1) year experience as a Claims Examiner for medical, dental claims and vision, subrogation, and accident claims, highly desired.
• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for accurate claim adjudication and/or benefit determination.
• Basic knowledge of medical terminology.
• Familiarity with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
• Good verbal and written communication skills.
• Proficiency in 10-key by touch data entry/type 40 WPM and Microsoft Office (Word, Excel, Outlook, PowerPoint).
• Ability to work under pressure and adapt to changing environments.
• Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines.

Duties And Responsibilities

• Claims Processing & Quality Assurance:
  • Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, Blue Card, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, by calculating benefit due to approve or deny, based on SPD and within accepted corporate cycle timeframe.
  • Analyze patient and medical records to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly.
  • Examine claim files for accuracy: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation.
  • Research through all vendor portals, including but not limited to Valenz, Occunet, Anthem Resolve benefit and eligibility issues that require detailed knowledge, support for customers within the claims processing, Company and ERISA guidelines.
  • Process low to medium level claims, re-pricing corrections.
  • Research, resolve and respond to all correspondence and internal communication (Ops Connect) related to electronic and paper claims as assigned.
• Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation.
• Utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
• Meet and maintain individual and department productivity and quality standards.

Problem Solving, Judgement & Compliance

• Examine a problem, set of data or text and consider multiple sides of an issue, weighs consequences before making a final decision.
• Ensure compliance with all appropriate policies and practices, local, State, Federal regulations and requirements regarding claims and contract administration.
• Partner with peers to document and analyze functional requirements, identify gaps and alternative approaches to resolve problems.
• Contribute to defining and documenting standards and periodically reviewing them to integrate appropriate industry standards.
• Alert supervisors to potential higher risk compliance issues.
• Make timely and effective decisions based on available information.
• Recognize issues, analyze, solve problems, research, identify trends and determine actions needed to advance the decision-making process within a realistic timeframe.
• Follow up as necessary.
• Involves the appropriate people in defining, understanding the impact and resolving problems.

Other

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members.
• Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively.
• Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.

Physical Demands / Work Environment

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job, the employee is regularly required to communicate with others.
• The employee frequently is required to move around the office.
• The employee is often required to use tools, objects, and controls.
• This noise level in the work environment is usually moderate.