The Claims Examiner I reports to the Supervisor of Claims. Claims Examiner I is responsible for reviewing and processing medical, dental, vision, and electronic claims per state, federal, and health plan regulatory requirements and department guidelines, as well as meeting established quality and production performance benchmarks, including research and review of applicable documentation. The Claims Examiner I will thoroughly review, analyze, and research health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. The position will assist in resolving issues from providers, customer service, member services, health plan, and other internal customers.
Claims Processing & Quality Assurance
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Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, Blue Card, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, by calculating benefit due to approve or deny, based on SPD and within accepted corporate cycle timeframe.
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Analyze patient and medical records to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly.
- Examine claim files for accuracy: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation.
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Research through all vendor portals, including but not limited to Valenz, Occunet, Anthem
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Resolve benefit and eligibility issues that require detailed knowledge, support for customers within the claims processing, Company and ERISA guidelines. Process low to medium level claims, re-pricing corrections.
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Research, resolve and respond to all correspondence and internal communication (Ops Connect) related to electronic and paper claims as assigned.
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Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation. Utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
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Meet and maintain individual and department productivity and quality standards.
Problem Solving, Judgement & Compliance
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Examine a problem, set of data or text and consider multiple sides of an issue, weighs consequences before making a final decision.
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Ensure compliance with all appropriate policies and practices, local, State, Federal regulations and requirements regarding claims and contract administration.
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Partner with peers to document and analyze functional requirements, identify gaps and alternative approaches to resolve problems.
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Contribute to defining and documenting standards and periodically reviewing them to integrate appropriate industry standards.
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Alert supervisors to potential higher risk compliance issues
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Make timely and effective decisions based on available information
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Recognize issues, analyzes, solves problems, researches, identifies trends and determines actions needed to advance the decision-making process within a realistic timeframe. Follows up as necessary.
- Involve the appropriate people in defining, understanding the impact and resolving problems.
Other
- Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
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Maintain internet speed of 40MB download and 10MB upload and router with wired Ethernet.
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Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
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Maintain and service safety equipment (e.g. smoke detector, fire extinguisher, first aid kit).
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All other duties as assigned.
The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.
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High school education or equivalent: minimum three (3) to five (5) years of experience as a Health Claims Examiner or comparable industry experience preferred.
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A minimum of one (1) year experience as a Claims Examiner for medical, dental claims and vision, subrogation, and accident claims, highly desired.
- Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination
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Basic knowledge of medical terminology. Familiar with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
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Good verbal and written communication skills.
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Proficient in 10-key by touch data entry/type 40 WPM and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications.
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Ability to work under pressure and adapt to changing environment
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Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines.
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Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
- Home router with wired Ethernet (wireless connections and hotspots are not permitted).
- A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
- A functioning smoke detector, fire extinguisher, and first aid kit on site.
