Claims Examiner

Job Title

To perform this job, an individual must perform each essential function satisfactorily, with or without a reasonable accommodation; including, but not limited to:

• Configure, implement and administer a robust claims quality and auditing program
• Establish best practice claims payment methodology based on current CMS claims payment regulations
• Conduct root cause analysis on systemic issues; formulate action plan to avoid incorrect payment through review of contracts, Medicare claims payment rules, internal system and beneficiary impact
• Coordinate with Network Services and Provider Relations teams to ensure proper reimbursements
• Work closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment
• Conduct pre-pay and post-pay audits to verify accurate claim payments and/or denials
• Provide exceptional service to providers, internal and external customers in accordance with company values
• Forecast all staffing requirements; schedule workforce accordingly
• Complete regular review of internal reporting (ex., high dollar claims)
• Ensure regulatory compliance, quality and efficiency
• Participate and support ad-hoc audits as required
• Collaborate with Utilization Management Team as necessary
• Complete all assigned claim projects

Supervisory Responsibility

• Effective supervision, including hiring, training, scheduling, work allocation and problem resolution
• Responsible for performance evaluation of team members and making recommendations for appropriate action, as well as motivating team members to achieve peak performance and productivity
• Continuing education and development of team members to adapt to sales deviations and business restructuring
• Maintain a reliable staffing model to ensure appropriate staffing levels

Qualifications & Education

• Strong working knowledge of claims processing standards, CMS claims processing requirements and various Medicare fee schedules
• Knowledge of automated claims processing systems and other complex claim processing rules and regulations
• Proficient in processing/auditing claims for Medicare plans
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to Health Plan operations
• Position may require flexible hours, unscheduled overtime or occasional weekend work
• Education: Bachelor's degree preferred
• Experience: 2 years' experience with complex claims processing and/or auditing within the health insurance industry or medical healthcare delivery system
• 2 years' experience in a managed healthcare environment related to claims processing/auditing, including Medicare plans
• 2 years' experience with CMS requirements, and other complex claim processing rules and regulations
• 2 years' experience using Healthcare Common Procedure Coding Systems (HCPCS), CPT, ICD, Medicare codes
• Recent Institutional and Professional claim payment experience

Working Conditions

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The noise level in the work environment is usually moderate.
• Works in the field
• Interacts with patients, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lift, and moves intermittently during working hours.

Work schedule is approximate and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including on weekends and holidays as needed.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required to this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Performance Measurements

This Job Description may be modified at any time at the discretion of the employer as business operation may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with demonstrated ability to juggle and prioritize multiple, competing tasks and demands and to seek supervisory assistance as appropriate.

Employee Acknowledgement: I have read this job description and understand what is expected of me while I occupy this role: