What are the responsibilities and job description for the Medical Claims Examiner position at DGA Producer Pension and Health Plans?
REPORTS TO
Assistant Manager, Claims & Appeals
CONTACTS AND RELATIONSHIPS
The position interfaces with department management, department employees, and employees from other departments. The position also requires contact with participants and their families, business managers, other insurance companies, and healthcare providers (e.g. doctors and hospitals).
ESSENTIAL FUNCTIONS
- Accurate and timely processing of delegated claims per regulatory and contractual guidelines.
- Determine eligibility, medical necessity, reasonable and customary allowances, and appropriate coding.
- Research and respond to scheduled reports and claim inquiries sent by Blue Card and Blue Cross representatives in a timely manner.
- Investigate and adjudicate complex claim requests and claims requiring special handling, such as adjustments and complaints in accordance with Plan guidelines, policy contract language and departmental processes and standards.
- Write letters to participants and providers requesting additional information when necessary.
- Follow-up on pending claims.
- Work with Eligibility Department to resolve eligibility problems, add or delete dependents, address changes, etc.
- Act in accordance with all HIPAA Privacy and Security guidelines to ensure confidential handling of protected health information.
- Answer phone calls from participants and providers when necessary.
- Regular, predictable, and reliable attendance is required.
SKILLS AND ABILITIES
- Extensive knowledge of medical terminology, ICD9, ICD10, and CPT codes.
- Extensive knowledge of Plan benefits, group insurance, and Medicare principals.
- Knowledge of Coordination of Benefits rules.
- Ability to maintain production standards in a detail-oriented, quality-conscious service environment.
- Ability to work independently with minimal supervision.
- Good written and verbal communication skills.
EDUCATION AND EXPERIENCE
High school diploma with some college plus three years or more experience in health claims processing preferred.
PHYSICAL REQUIREMENTS
Possess manual dexterity sufficient to operate standard office machines. Ability to sit for extended periods of time. Position requires bending, reaching, walking, and lifting of up to 10 lbs.
Location and Schedule
Onsite. Position eligible for alternative workweek schedule.
Salary
$22.12 per hour.
Salary : $22