Insurance Claims Examiner II

Level II

• Analyzes and processes minimum of 200 claims daily to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims
• Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations
• Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments
• Affords assistance with other research and development projects as directed by Management; obtains and maintains necessary certification for Health Insurance Marketplace CAC
• Provides training and guidance through expert knowledge of claims administration and adjudication to Insurance Department staff; responsible for the timely response to formal appeals from members, employees, clients and providers
• Reviews, resolves and/or escalates Level 2 claims appeals; releases claims up to the designated draft authority for Level 2 Claims Examiner
• Works with the Customer Service Coordinator to manage and provide direction to the utilization review and case management vendor; identifies and manages claims with potential subrogated recovery
• Ensures that claims adjudication complies with all FCPID standards and protocols; reviews claims for possible abuses and/or fraud and brings to the attention of management
• Oversees the repricing processes to ensure the integrity of the product; investigates claims referred by staff for possible abuse and fraud

Level III

• Analyzes and processes minimum of 400 claims to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims
• Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations
• Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments
• Affords assistance with other research and development projects as directed by Management; obtains and maintains necessary certification for Health Insurance Marketplace CAC
• Provides training and guidance through expert knowledge of claims administration and adjudication to Insurance Department staff; responsible for the timely response to formal appeals from members, employees, clients and providers
• Reviews, resolves and/or escalates Level 2 claims appeals; releases claims up to the designated draft authority for Level 2 Claims Examiner
• Works with the Customer Service Coordinator to manage and provide direction to the utilization review and case management vendor; identifies and manages claims with potential subrogated recovery
• Ensures that claims adjudication complies with all FCPID standards and protocols; reviews claims for possible abuses and/or fraud and brings to the attention of management
• Oversees the repricing processes to ensure the integrity of the product; investigates claims referred by staff for possible abuse and fraud

What You’ll Need To Be Successful

• High School Diploma or GED
• Five (5) years of experience in medical claims processing
• Three (3) years in customer service
• Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards
• Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology
• Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment
• Must successfully pass all applicable background checks and drug screens

Benefits

• Approximately 5 weeks of paid time off annually
• 3 weeks of paid holidays
• Premium free health insurance
• Flexible spending accounts
• Short term disability
• Life insurance
• 401k with match