Claims Examiner - Jefferson Health Plan

Job Duties

• Able to work in a constant state of alertness and safe manner
• Accurately adjudicates claims in compliance with data entry rules, On Line Processing Rules and contractual agreements
• Reviews pended claims on a daily basis, assuring that all appropriate documentation is completed before adjudication
• Accurately completes service forms for pended claims and routes to designated areas for resolution
• Reviews audit results on a weekly basis, correcting errors in the claims processing system within designated timeframes
• Follow established procedures and guidelines for claims processing and high dollar claim review
• Maintains minimum performance standards as specified by departmental policies, such as claim production and accuracy
• Keeps current with Claims Department policies and procedures
• Aid the unit in meeting and maintaining performance standards

Minimum Qualifications

• High School Diploma/GED
• Ability to maintain strict confidentiality of patient information obtained in the performance of job function

Preferred Qualifications

• 2 years claims processing experience or provider billing experience
• Excellent communication skills required-both oral and written
• Basic understanding of computer applications
• General understanding of the principles of Managed Care

Physical Demands

• Lift and carry 25 lbs.
• Frequent sitting/standing
• Frequent keyboard use
• Patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.