Claims HMO - Senior Claims Examiner

Senior Claims Examiner

The Senior 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. The Senior Claims Examiner will generally handle claims involving multiple lines of business or has been permanently assigned additional responsibilities beyond general claims examination.

Key responsibilities include:

• Examining and adjudicating claims for multiple lines of business that have pended for review utilizing resources, tools, knowledge and decision-making in determining appropriate actions.
• Enter claims information using the processing software to compute payments, allowable amounts, limitations, exclusions and denials.
• Identify and communicate trends or problems identified during adjudication process.
• Accurately resolves most unique problems or situations without supervisor involvement.
• Contribute to the creation of a pleasant working environment with peers and other departments.
• Assist in investigating and solving claims that require additional research.
• Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.
• Assist in mentoring or development of new examiners.
• Perform other 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 most 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 for multiple lines of business.
• Demonstrated understanding of unbundling methods, COB, and other over-billing methodologies.
• 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.
• One year actual claims examining experience within CommunityCare or another healthcare environment is 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.