Remote WORK FROM HOME / CLAIMS PROCESSOR - AT

The Claims Examiner is responsible for determining the proper payment (if any) of medical claims by group health plans, based upon specific knowledge and application of each client's customized plan(s).
Independently review and analyze health care claims for: 1) reasonableness of cost; and 3) fraud.
Determine whether a health plan provides benefits in connection with the claim submitted and the level of benefits to be paid to the provider.
Log claims negotiated in Access database and create weekly summary reports.
Consult with other entities who can offer additional evaluation of a claim.
Process claims in the QicLink System.
Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.Review billed procedure and diagnosis codes on claims for billing irregularities.
Analyze claims for billing inconsistencies.
Review and analyze specific procedure and diagnosis codes for medical necessity.
Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
Review Suspended Claim Reports and follow up on open issues.
Attend continuing education classes as required, including but not limited to HIPAA training.
High School Diploma, College and Advanced Degrees Preferred or equivalent work experience required.

Must have a minimum of 5 years of medical claims analysis experience (including dental and vision claims analysis).
Knowledge of computer systems and CPT and ICD-9 coding terminology.
Continuing education in all areas affecting group health and welfare plans is required.
Customer Focus
This is standard desk role requiring extended periods of sitting and computer work.

Remote

Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life and Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend.