Claims Examiner Job Description

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.

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Claims Examiner Job Description Template

Our company is looking for a Claims Examiner to join our team.

Responsibilities:

  • 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.

Requirements:

  • 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.