Claims Examiner II

Location: Birmingham, AL

Work Schedule: After a period of 100% onsite training, this position will transition to mostly remote with occasional work needed at the Viva Health headquarters in downtown Birmingham.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan, receiving a 5 out of 5 Star rating - the highest rating a Medicare Advantage Plan can achieve and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Benefits

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Healthcare Reimbursement Account
• Paid Parental Leave
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Employee Assistance Program

See more about the benefits of working at Viva Health - https://www.vivahealth.com/careers/benefits

Job Description

The Claims Examiner II will administer all claims adjudication processing professional and facility medical, dental and vision claims in accordance with regulatory guidelines and contractual agreements based on VIVA HEALTH guidelines. This position will assist with additional duties such as reports, following up with departments on routed claims and other duties assigned by management.

Key Responsibilities

• Adjudicate claims submitted by providers and members assigned via claims workflow.
• Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated.
• Correctly match authorizations to ensure claims are processing appropriately based on established guidelines.
• Understand how different processes drive benefit determinations for different claims types based on authorization code sets and claims types.
• Work with internal departments to resolve issues preventing claims from processing or enhancing processing capabilities.

REQUIRED:

• 2 years’ college or equivalent claims adjudication experience
• 1–2 years’ experience with claims processing
• Ability to thrive in a production environment where quality and quantity are highly measured, including recognizing and correcting quality errors
• Demonstrate excellent customer service skills through written and verbal communication
• Organized, detail oriented and skilled at prioritizing and multitasking
• Ability to work in a team environment, remain flexible to changes, and recognize responsibilities, actively participate with others to accomplish assignments and achieve desired goals
• Knowledge of medical terminology, ICD, CPT, and HPCS
• Basic computer skills including Microsoft Word, Excel, Outlook
• Understanding of Claims Payment System in order to process claims, prepare reports, and correspondence

PREFERRED:

• Professional and/or hospital claims adjudication experience, preferably in the healthcare/medical field
• CRT data entry experience