Claims Examiner I

About the role

As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity.

Responsibilities

• Day-to-day processing of claims for accounts
• Responsible for processing of claims (medical, dental, vision, and mental health claims)
• Claims processing and adjudication
• Claims research where applicable. Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic)
• Investigation and overpayment administration: Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers
• Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records
• Utilize systems to track complaints and resolutions
• Resolve claims appeals, research benefits, verify correct plan loading

Requirements

• 2+ years related work experience
• Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry
• High school diploma or GED
• Knowledge of CPT and ICD-10 coding required
• Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required
• Proven judgment, decision-making skills and the ability to analyze
• Ability to learn quickly and multitask
• Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers
• Concise written and verbal communication skills required, including the ability to handle conflict
• Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding
• Review of multiple surgical procedures and establishment of reasonable and customary fees

Qualifications

• Some college courses in related fields are a plus
• Other experience in processing all types of medical claims helpful
• Data entry and 10-key by touch/sight

Benefits

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission.