CLAIMS EXAMINER

Job Title

Responsibilities:

• Evaluate and determine coverage for benefits based on the member's plan/client's processing guidelines.
• Maintain quality and production standards as defined by client contract and/or management determination of need.
• Manage time adequately to ensure proper turn around for all tasks such as new claims, pending claims, customer service requests and audit feedback.
• Work with teammates and supervisor to ensure the needs of the client are being met.
• Assist in development of process improvement initiatives.
• Ability to look at processes and offer suggestions for hot keys and efficiencies.

Accountabilities:

• Successfully completes all training programs as required.
• Acts in accordance with all HIPAA Privacy and Security guidelines to ensure confidential handling of protected health information.
• Execute prompt analytical decision making/research with specific attention to detail.
• Comply with State laws, policy and company procedures.
• Utilize specified claims production tracking and reporting procedures.

Education & Experience:

• High school diploma or GED
• One year of claims adjudication experience or equivalent medical billing office experience is preferred.

Language Requirements:

• Read and comprehend instructions, discussion, correspondence and memos.
• Hold a conversation and communicate ideas in an understandable manner.
• Medical terminology and medical claims coding knowledge is preferred.

Physical Requirements:

• Light repetitive movement of digits.
• Stationary 80% of time at a work station keying and viewing a computer screen.
• Moving, positioning, and reaching intermittently.

Other Requirements:

• Must be able to maintain confidentiality.
• Must be detailed oriented.
• Must have ability to stay focused.
• Must have basic math skills.
• Must have reading comprehension skills to read and apply the provisions of specific plan documents.
• Must have ability to work in a windows environment on a PC.
• Must have effective communication skills.
• Must be able to work in a team environment.
• Must be flexible with schedule, including working more or less than a 40 hour week when client inventory levels fluctuate.