Claims Examiner

Job Purpose

The Claims Examiner & Support Specialist Level I is responsible for accurately processing health plan delegated claims, addressing provider inquiries via phone calls, and handling various administrative tasks within the department. In addition, you will be responsible for contributing to the growth and success of the company while upholding our Mission, Vision and Values.

Essential Job Duties & Responsibilities

1. Processing Health Plan Delegated Claims:

• Reviewing claim submissions for accuracy and completeness.
• Verifying information provided in claims to ensure it aligns with established guidelines.
• Adjudicating claims according to the policies and regulatory guidelines set by the health plans.
• Ensuring the accurate and timely processing of delegated claims.

1. Answering Phone Calls:

• Handling incoming phone calls from healthcare providers and other stakeholders.
• Providing prompt and accurate responses to inquiries related to claims processing.
• Documenting phone calls to include topics discussed and resolution.
• Addressing concerns and questions from providers regarding claims.
• Assisting with claim-related issues and resolving problems over the phone.

1. Administrative Functions:

• Performing various administrative tasks to support the efficient operation of the claims processing department.
• Conducting data entry accurately and efficiently.
• Logging disputes and tracking their resolution process.
• Processing incoming mail related to claims and ensuring timely distribution.
• Handling other clerical duties as assigned by supervisors or managers.

1. Other Duties as Assigned:

• Being flexible and willing to take on additional responsibilities as needed.
• Adapting to changes in workflow or procedures within the claims processing department.
• Collaborating with team members to achieve overall departmental goals.

To excel in this role, attention to detail, knowledge of healthcare claim processing, and effective communication skills are crucial. You must be familiar with the specific guidelines and policies of the health plans you are working with and stay updated on any changes. Additionally, maintaining a customer-centric approach when dealing with inquiries and issues is essential to ensure a positive experience for providers and stakeholders.

Experience

• 1 year of call center experience preferred
• 6 months claims adjudication experience preferred
• 1 year experience in Claims department is a plus

Education

• High School diploma or equivalent GED

Knowledge, Skills & Abilities

• Basic knowledge of healthcare terminology, coding, and claim processing procedures.
• Strong attention to detail and accuracy in data entry.
• Good communication skills, both written and verbal.
• Ability to adapt to changing guidelines and procedures.
• Familiarity with relevant software and computer skills for data entry and claims processing systems, a plus.
• Basic knowledge of Microsoft Office including Outlook, Word, Excel, and Teams.
• Data Entry/Typing skills, a minimum of 50 words per minute.
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers.
• Ability to multi task, as needed.