Top 3 Examiner Jobs in Crandon, Wi

Insurance Claims Examiner II
Forest County Potawatomi Community —Crandon, WI
- Customer service
- 5 years
- Word processing
- Paid holidays
- Disability insurance
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Insurance Claims Examiner II

Forest County Potawatomi Community -
Crandon, WI

Quick Apply

Job Details

Benefits

Paid holidays
Disability insurance
Health insurance
Dental insurance
Flexible spending account
Paid time off
Vision insurance
401(k) matching
Life insurance

Qualifications

National Correct Coding Initiative (NCCI) guidelines
Customer service
Word processing
Spreadsheets
Health insurance policy knowledge
CMS
Regulatory compliance in claims processing
Dental insurance
Windows
High school diploma or GED
CMS regulatory compliance
Supervising experience
Team management
Desktop applications
Centers for Medicare & Medicaid Services (CMS) billing regulations
Productivity software
Medical terminology

Full Job Description

Here’s what you’ll be doing:

Level II

Level III

Analyzes and processes minimum of 200 claims daily to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims

Analyzes and processes minimum of 400 claims to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims

Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations

Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments

Assists with other research and development projects as directed by Management; obtains and maintains necessary certification for Health Insurance Marketplace CAC

Provides training and guidance through expert knowledge of claims administration and adjudication to Insurance Department staff; responsible for the timely response to formal appeals from members, employees, clients and providers

Reviews, resolves and/or escalates Level 2 claims appeals; releases claims up to the designated draft authority for Level 2 Claims Examiner

Works with the Customer Service Coordinator to manage and provide direction to the utilization review and case management vendor; identifies and manages claims with potential subrogated recovery

Ensures that claims adjudication complies with all FCPID standards and protocols; reviews claims for possible abuses and/or fraud and bring to the attention of management

Oversees the repricing processes to ensure the integrity of the product; investigates claims referred by staff for possible abuse and fraud

What you’ll need to be successful:

Level II

Level III

High School Diploma or GED

Five (5) years of experience in medical claims processing

Three (3) years in customer service

Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards

Two (2) years in a lead or supervisory capacity

Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology

Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards

Knowledge of insurance principles and/or procedures

Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology

Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment

Knowledge of insurance principles and/or procedures

Must successfully pass all applicable background checks and drug screens

Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment

Must successfully pass all applicable background checks and drug screens

Benefits you’ll love:

Approximately 5 weeks of paid time off annually
3 weeks of paid holidays
Premium free health insurance
Flexible spending accounts
Short term disability
Life insurance
401k with match

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.

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Insurance Claims Examiner II

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