Senior Claims Examiner

The Claims Examiner Senior is responsible for reviewing, analyzing, researching, and resolving complex medical claims in accordance with claims processing guidelines and desktops, as well as, ensuring compliance with federal regulations. Analyze medical claim information and take appropriate action for payment resolution in accordance with policies and procedures, desktops, processing guidelines, and federal regulations. Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc. Work claim projects resulting from overpayments or underpayments related to manual processing errors, benefit updates, and/or contract, fee schedule changes. Process provider refunds, reconsiderations, and direct member reimbursements. Process medical claim adjustments, recovery of claim overpayments, and execution of claim batch adjudication. Solve moderately complex claims and escalate issues to the Claims Team Lead, Supervisor or Manager. Assist with database improvements and testing for system upgrades, conversions, or implementation of new processes. #J-18808-Ljbffr