Senior Examiner, Claims

Essential Job Duties

• Evaluates the adjudication of claims using standard principles, and state-specific regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and claims processing errors.
• Manages a caseload of claims - procures all medical records and statements that support the claim.
• Makes recommendations for further investigation and/or resolution of claims.
• Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication, and recommends solutions to resolve issues.
• Identifies and recommends solutions for error issues as it relates to pre-payment of claims.
• Maintains meticulous notes and records for each claim.
• Manages a caseload of various types of complex claims - procures all medical records and statements that support the claim.
• Maintains compliance with state and federal regulatory compliance regulations on turnaround times and claims payment for multiple lines of business (LOBs).
• Maintains department quality and production standards.
• Supports all claims department initiatives to improve overall efficiency.
• Completes claims projects as assigned.

Required Qualifications

• At least 2 years of experience in claims, and/or customer service experience in a clerical role - preferably in a managed care setting, or equivalent combination of relevant education and experience.
• Research and data entry skills.
• Organizational skills and attention to detail.
• Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
• Customer service experience.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Health care claims/billing experience.