Claims Examiner

• May be entitled to translation/bilingual, shift or other wage premiums as governed by the applicable collective bargaining agreement. Please refer to the respective collective bargaining agreement for additional information on such wage premiums: https://www.lmpartnership.org/local-contracts.
  
  

Job Summary

Through comprehensive assessment and analysis, adjudicates managed healthcare claims/bills, authorizations and referrals, for payment or denial within contract agreement and/or regulatory requirements. Performs these duties using industry standard knowledge of managed healthcare claim/bill payment processing and medical regulations, verifies and updates relevant data into various computerized internal and external systems.

Essential Responsibilities

• For all lines of business analyze claim holds/pends, research and track required claim information to adjudicate professional and hospital claims/bills.
• Proactive and or responsive outreach to provider, members and other customers that could include phone calls, emails or other methods as needed.
• Proactively communicate with internal departments as appropriate to resolve claims issues promptly.
• Provides input to supervisor and training and development team regarding training and educational tools to enhance department production and processes.
• Proactively communicate with internal departments as appropriate to resolve claims issues promptly.
• Provides assistance to prepare materials as needed to the leads, supervisors and managers for external audits.
• Communicate problems and/or trends to leads and management. Understand and apply county, state and federal regulations.
• Other duties as assigned within department job functions.
  
  

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