Claims Examiner

Job Description

Job Description

Position Summary: 

Responsible for the accurate and timely adjudication of health insurance claims in accordance with established production and quality department standards by performing the following duties:

Qualifications:

• High School or General Education Diploma (GED) and two to four years related experience and/or training; or equivalent combination of education and experience.
• Medical Coding Certification, CPC or equivalent preferred.
• Knowledge of word processing software, spreadsheet software, internet software, and Epic software.

'Essential Duties and Responsibilities: 

1. Adjudicates and enters claims for all lines of business according to benefit plan designs and regulatory standards.
2. Reviews claims based on coverage benefits, coding guidelines, medical review determination, billing discrepancies and cost containment measures.
3. Thorough knowledge of coding structures (CPT, HCPCS, Revenue codes, ICD10, DRG etc.)
4. Identifies third party or coordination of benefits issues and notifies designated claims department Coordination of Benefits (COB) personnel for timely review and resolution. 
5. Knowledgeable of COB and familiarity with benefits and benefit calculations
6. Ability to understand and manually calculate all types of claims pricing (Medicaid, Medicare, and UCR - Usual, Customary and Reasonable, etc.)
7. Identifies inappropriate or questionable claims and refers to Claims Analysts for review.
8. Researches all complex claims, disputes and appeals thoroughly to make accurate payment decisions in a timely manner with input from the Claims Analysts for quality assurance.
9. Processes claim corrections and COB updates via interdepartmental customer relationship management process. 
10. Generates and reviews production reports daily for quality and training purposes.
11. Maintain quantity/quality department goals regarding the number of claims entered and accuracy percentages.
12. Complete side by side and peer training as necessary for educational opportunities.
13. Assists with projects and clerical support as needed.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Skills and Abilities : 

• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
• Ability to write routine reports and correspondence.
• Verbal and written communication skills.
• Ability to perform arithmetic calculations.
• Ability to work independently.
• Ability to meet deadlines.
• Ability to maintain a good rapport and cooperative working relationship with the team.
• Ability to speak effectively before groups of customers or employees of organization.
• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.
• Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

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. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment: 

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. 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.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.

Background Screening Notice:
In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

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