The Senior Claims Examainer is responsible for reviewing and adjudicating complex Facility, ASC or specialty claims submitted via paper or electronically. This role involves advanced administrative, operational, and customer support duties that require independent initiative and judgment. The types of claims include inpatient, coordination of benefits (COB) for high-dollar cases, dialysis, oncology/chemotherapy, home health agency, skilled nursing facility (SNF), hospital exclusions, and claim adjustments. The Claims Examiner III also audits professional claims for accuracy.
Functions & Job Responsibilities
- Determine whether to return, deny, or pay institutional claims following organizational policies and procedures.
- Conduct end-to-end claims audits to ensure claims are processed accurately according to benefits assignment, applicable contracts, pricing, and configuration rules.
- Ensure institutional claims meet compliance guidelines.
- Perform claims testing on claims configuration and enhancements.
- Focus decisions on methods, tactics, and processes for completing administrative tasks/projects.
- Regularly exercise discretion and judgment in prioritizing requests, interpreting and adapting procedures, processes, and techniques, and work under limited guidance due to previous experience and breadth and depth of knowledge of administrative processes and organizational knowledge.
- Adjudicate complex professional and institutional claims.
- Assist with training and mentoring new team members.
- Assist with testing new claim processing procedures or projects.
- Meet performance measurement standards for productivity and accuracy.
- Adjudicate claim adjustments.
- Review and correct claims involving data integrity issues.
- Interface with other Champion Payor Solutions Departments, when necessary, regarding claims issues.
- Participate in Claims Department Team Meetings and other activities as needed.
- Support all department initiatives in improving overall efficiency.
- Identify and recommend solutions for error issues as they relate to the pre-payment of claims.
- Oversee the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication and recommending solutions to resolve these issues.
- Manage a caseload of various types of complex claims. Procure all medical records and statements that support the claim.
- Meet department quality and production standards.
- Meet State and Federal regulatory Compliance Regulations on turnaround times and claims payment for multiple lines of business.
- Perform other duties as assigned.
Qualifications
Education & Experience:
- Associate degree or equivalent combination of experience in health insurance or related fields, which would provide the necessary knowledge, skills, and abilities to successfully perform the work.
- Three or more (3 +) years of experience in examining and processing institutional claims for inpatient, dialysis, SNF, and home health using Medicare prices.
- Two (2) years of experience in examining and processing medical claims, professional or institutional.
- Experience with Medicare/Medi-Cal is preferred.
- Experience with claim adjustments, provider appeals, and/or disputes is preferred.
Skills:
- Advanced knowledge and skills in medical terminology, HCPCS/CPT, and ICD-9/ICD-10.
- Knowledge of Centers for Medicare and Medicaid Services claims payment guidelines.
- Strong analytical skills, including the ability to analyze and organize data.
- Strong attention to detail.
- Excellent organizational, oral presentation, and written and verbal communication skills.
- Proficiency in MS Office products, including PowerPoint, Excel, and Word.
- Ability to provide effective leadership and direction within an organization.
- Meet and consistently maintain production standards for Claims Adjudication.
Job Type: Full-time
Pay: From $29.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Work Location: In person
