Description

POSITION SUMMARY: 

The Claims Examiner serves our customers by processing medical claims, ensuring quick and accurate turnaround, and taking responsibility for payment of claims in compliance with current policies and 

procedures. 

ESSENTIAL DUTIES AND RESPONSIBILITIES: 

• Process Medical Claims (both Facility and Professional) by calculating benefit due, initiating payment, or denying claim. 

• Verifies eligibility of members for accurate benefit payments. 

• Identifies problems or questionable claim situations. 

• Generates information request and declination letters to providers and members. 

• Reviews claim documentation; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, etc. 

• Documents medical claims actions by completing forms, reports, logs and records where necessary. 

• Ensure legal compliance and protect confidential information by following company policies, procedures, guidelines, as well as State and Federal regulations. 

• Maintains quality client services by following client service practices; responding to client inquiries as necessary. 

Qualifications

QUALIFICATIONS: 

This Claims Examiner must be highly motivated and a self-starter. This individual must be a critical thinker and be able to grasp benefit concepts. The Claims Examiner must be detail-oriented with the ability to manage multiple priorities and time-sensitive tasks. Excellent client services skills including verbal and written communication skills along with strong interpersonal and problem-solving skills are required. This individual must also possess an ability to work collaboratively in a team environment. To perform the position, an individual must be able to satisfactorily perform each essential duty. The requirements listed below are representative of the knowledge, skill, and/or ability required.

EDUCATION AND/OR EXPERIENCE: 

It is required that individuals have completed a bachelor’s degree or have equivalent job experience. Two plus years’ experience as a Medical Claims Examiner is required. Must possess a thorough understanding of group medical claims, including ICD-10, HCPCS/CPT coding, HCFA 1500 and UB92. Must have knowledge of claims editing and submission capabilities. Javelina application experience preferred but not required.

CERTIFICATIONS/LICENSURE/REGISTRATIONS: Preference will be given to individuals who have completed the CEBS (Certified Employee Benefits Specialist) or have obtained their life and health insurance license.