Claims examiners review claims after they are submitted to ensure claimants and adjusters followed proper guidelines. They may assist adjusters with complicated claims or when, for example, a natural disaster occurs and the volume of claims increases.
Claims Examiner Job Description Template
Our company is looking for a Claims Examiner to join our team.
- Provide backup for other examiners within the Department;
- Ability to evaluate policy language and apply to claim;
- Adhere to organizational Policies and Procedures;
- Adjudicate claims in accordance with departmental policies and procedures and other rules applicable to specialty claims;
- Meets production standards of 100-150 Hospital claims per day and 200-250 IPA claims as established by claims management;
- Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines;
- Requests additional information or follow up with provider for incomplete or unclean claims;
- Conduct internal and external presentations;
- Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims;
- Adjudication of Commercial and Medicare Advantage claims;
- Complete special projects as needed or requested;
- Ability to make phone calls to Provider/Billing offices when necessary based on department guidelines;
- Applicable regulatory legislature;
- Requires general understanding of liability and damage assessment skills;
- Ability to effectively communicate with External and Internal teams to resolve claims issues.
- Basic knowledge of Microsoft Office Outlook, Word and Excel;
- ICD-9 and ICD-10 and CPT-4 coding knowledge preferred;
- Maintain regular attendance based on agreed-upon schedule;
- Good, basic Mathematical skills a plus;
- Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers;
- Experience in a managed care environment preferred;
- Ability to abide by Molina’s policies;
- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA);
- Good working knowledge of the 10 key bad as well as the main keyboard;
- Good verbal and written communication skills;
- General knowledge of PC;
- High School Diploma or GED Equivalent;
- Must be detail oriented and have the ability to work independently.