What are the responsibilities and job description for the Claims Examiner II position at MagnaCare?
Primary Responsibilities
- Review and adjudicate claims submitted for reimbursement that fall outside auto adjudication standards on a daily basis, ensuring compliance with quality, productivity, and timeliness requirements.
- Applying medical policies, contractual provisions, and operational procedures to ensure precise adjudication and adjustments.
- Generate correspondence, such as letters and questionnaires, to gather additional information from customers and providers; may also initiate phone inquiries.
- Collaborate with Customer Service to address and resolve customer inquiries and concerns effectively.
- Research and resolve client inquiries and escalations in a timely manner, collaborating with internal teams as needed to ensure effective resolution.
- Execute client-requested claim adjustments and provide clear, concise written responses to client inquiries within established deadlines.
- Perform in-depth research on account receivables and spreadsheets that require claim adjustments, delivering thorough and clarifying responses to providers and clients.
- Must be adaptable and willing to provide backup support across various departments and roles as needed
- Responsible for processing all claim types including Professional and Facility claims
- Perform Claim Adjustments as needed. Execute client-requested claim research and adjustments and provide clear, concise written responses to client inquiries within established deadlines
- Strong knowledge of healthcare contracts, medical terminology, and claims processing procedures.
- Prior experience processing claims is required.
- Minimum 1 year of experience in medical billing, claims adjudication, or a related role.
- Excellent written and verbal communication skills, with the ability to manage inquiries professionally and efficiently.
- Strong analytical skills with the ability to research and resolve complex claim issues.
- Proficiency in Microsoft Office Suite, particularly Microsoft Word and Excel.
- Ability to meet production and quality standards while managing multiple priorities.
- Strong problem-solving skills and the ability to maintain professionalism under pressure.