Claims HMO - Claims Examiner 140-1006

Claims Examiner

The Claims Examiner is responsible for examining claims that require review prior to being adjudicated. The examiner will use their resources, knowledge and decision-making acumen to determine the appropriate actions to pay, deny or adjust the claim. Examiners are expected to meet performance expectations in accuracy and efficiency.

Key responsibilities include:

• Examining and adjudicating claims that have pended for review utilizing resources, tools, knowledge and decision-making in determining appropriate actions.
• Identifying claims requiring additional resources and routing to the team lead, supervisor or other departments as needed.
• Entering claims information using the processing software to compute payments, allowable amounts, limitations, exclusions and denials.
• Identifying and communicating trends or problems identified during the adjudication process.
• Contributing to the creation of a pleasant working environment with peers and other departments.
• Assisting in investigating and solving claims that require additional research.
• Consistently learning and adapting to changes related to claims processing, benefits, limits and regulations.
• Performing other job-related duties as assigned.

Qualifications:

• Self-motivated and able to work with minimal direction.
• Ability to read and understand claims processing manuals, medical terminology, CPT codes, and perform basic processing procedures.
• Ability to read and understand health benefit booklets.
• Demonstrated learning agility.
• Successful completion of Health Care Sanctions background check.
• Knowledge in the contracted managed care plan terms and rates.
• General understanding of unbundling methods, COB, and other over-billing methodologies.
• Must have high attention to detail.
• Proficient in Microsoft applications.
• Ability to perform basic mathematical calculations.
• Possess strong oral and written communication skills.

Education/Experience:

• High School Diploma or Equivalent required.
• Two years related work experience in claims processing, claims data entry or medical billing OR medical related education to meet minimum two years required.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin.