Claims Examiner Senior - Health Plan Admin

About the role

This position is responsible for reviewing, analyzing, researching, and resolving complex medical claims in accordance with claims processing guidelines and desktops, ensuring compliance with federal regulations. The role collaborates with Business Configuration, Network Management, Provider Data, Complaints, Appeals and Grievances, and other operational departments to ensure validation and quality assurance of claims processing.

Responsibilities

• Analyze medical claim information and take appropriate action for payment resolution in accordance with policies, procedures, desktops, processing guidelines, and federal regulations.
• Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc.
• Work claim projects resulting from overpayments or underpayments related to manual processing errors, benefit updates, and/or contract or fee schedule changes.
• Process provider refunds, reconsiderations, and direct member reimbursements.
• Process medical claim adjustments, recovery of claim overpayments, and execution of claim batch adjudication.
• Solve moderately complex claims and escalate issues to the Claims Team Lead, Supervisor, or Manager.
• Assist with database improvements and testing for system upgrades, conversions, or implementation of new processes.
• Serve as a resource to assist with training new associates, retraining current associates on new/updated desktops/policies, and report staff progress, deficiencies, and training needs to management.
• Set high standards of performance and promote teamwork to achieve established team goals while maintaining a positive, professional attitude.
• Contact and respond to internal and external customers for resolution on claim issues.
• Assist claims leadership to identify claim trends, gaps in workflow, and create/update desktops, policies, and procedures.
• Collaborate with and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate completion of tasks/goals.
• Organize and prioritize work to meet deadlines.
• Demonstrate good judgment, initiative, and problem-solving abilities.
• Attention to detail is critical to ensure timely and accurate processing of claims.
• Consistently meet established productivity and quality standards.
• Follow CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA) to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
• Perform other duties as assigned by management to support claims functions focused on achieving both departmental and organizational objectives.

Requirements

• Associate's degree or equivalent job-related experience required.
• Minimum of 3 years’ experience processing medical claims in the healthcare industry.
• Prior experience working with managed care, Medicare, Medicare Advantage, Health Exchange, and TRICARE is highly desirable.
• Must be knowledgeable about medical terminology, CPT, HCPCS, ICD-10, Revenue Codes, CMS-1500 and CMS-1450/UB-04 claim forms, and reimbursement methodologies.
• Must have excellent written, verbal, organizational, and interpersonal communication skills.
• Must be proficient in Microsoft Office, including PowerPoint, Excel, Word, Outlook, spreadsheets, and database skills.

Schedule

5 days, 8 hours per day.