Sr. Medical Claims Examiner/ Representative

Role Overview

MPI is seeking a Senior Medical Claims Examiner/Representative. The Examiner/Representative reviews and processes escalated health claims for reconsideration, confirms accumulator benefits to outside vendors, and communicates (by phone, email, and written correspondence) with participants and providers’ offices about claims and benefit issues.

What You Will Need

• High school Diploma or GED required. Some college preferred.
• 2+ years of verifiable claims processing experience with quality average of 95%.
• 1+ years of customer service/call handling experience in a healthcare environment.
• Knowledge of: CPT, HCPCs, ICD-9, COB, and Medical Terminology.
• Intermediate level of proficiency in PC skills including MS Word, Outlook, and Excel.
• Familiarity with QNXT configuration.
• Clear and effective oral and written communication skills.
• Excellent attendance & reliability with the ability to work overtime/extended hours as needed.
• Strong organizational skills and attention to detail.
• Able to handle fast-paced work while meeting production and quality assurance goals/standards.
• Good interpersonal skills; able to interact with individuals at all levels.
• Able to accept direction and developmental guidance from lead and manager.
• Flexible team player, with a positive, cooperative, and helpful attitude; willing to assume additional duties as needed.

Preferred Qualifications

• Knowledge of MPI Plan benefits.
• Working knowledge of Anthem WGS Claims system.
• In-depth knowledge of V3 Eligibility system.

What You Will Do

• Review and process requests for claim adjustments including responses to providers and participants.
• Process a high volume of complex or technically difficult claims.
• Perform investigation / research as needed for the processing of medical claims.
• Make outbound calls to MPI participants and/or providers regarding the status of a claim.
• Contact providers regarding misrouted or unidentified claims.
• Contact providers requesting additional information (medical records, consultation notes, progress notes and prescriptions).
• Actively execute appropriate claim activities to ensure consistent quality/configuration of claims processing.
• Document issues and actions effectively and efficiently utilize internal systems.
• Test configuration changes.
• Participate in development and maintenance of departmental procedures.
• Provide accumulator benefits to MPI external medical partners.
• Complete other duties as assigned including, but not limited to, assisting other departments and units as needed.

Compensation & Benefits

• This is a Union-Affiliated position.
• MPI offers a comprehensive benefits package, including free medical, dental, and vision coverage, generous paid time off, retirement benefits, and professional development opportunities.