POSITION RESPONSIBILITIES: The Claims Examiner is responsible for the accurate and timely processing of medical, dental, vision and prescription drug claims. The incumbent is expected to provide courteous and prompt responses to customer inquiries. The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position. ESSENTIAL JOB FUNCTIONS: Essential job functions include the following.
Other functions may be assigned as business conditions change. Verifies the accuracy and receipt of all required documentation for each claim submitted. Collaborates with providers, plan participants, other claims payers, or any other party necessary to obtain information necessary to accurately process a claim. Analyzes information necessary for processing.
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This includes, but is not limited to, general participant and provider information, managed care affiliation, diagnosis codes, dates, place, type of service, procedure codes, and charges. Assures that the system processes the claim correctly and determines payment according to the plan as written. Word-processes correspondence to plan participants and providers in reference to pre-determinations and in response to basic benefit questions. Answers telephone calls from plan participants, group contacts, and customer service representatives pertaining to benefits and claims inquiries.Resolves problematic claims with the assistance of the Team Leader, Claims Manager and/or the Director of Claims. Assigns critically ill patients to large case management. Assists the case manager with direct negotiation and the efficient use of benefits. Assists other examiners as needed due to workload requirements, including assigned back-up when examiners are absent.
Aids the Team Leader and/or the Claims Manager in the resolution of claim appeals and disputes by providing documentation for review. Researches, calculates and requests refunds when necessary. Contributes to the daily workflow with regular and punctual attendance. Thoroughly researches and completes renewal reports in a timely manner in consultation with the Marketing Department.
Process eligible claims on groups before the end of their stoploss contract renewal period. NON-ESSENTIAL JOB FUNCTIONS: Performs related or other assigned duties as required or directed. Assists the Legal Department with subrogation claims as necessary. Attends various group meetings as required.
Assists with audits as needed. Assists with plan benefit set-up and changes as needed. SUPERVISION EXERCISED: None. PHYSICAL WORKING CONDITIONS: Physical requirements are representative of those that must be met to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Sitting 80% Reaching Some Standing 10% Manual Dexterity High Walking 10% Telephone Yes Kneeling Some Computer Screen High (visual acuity corrected to 20/30) Bending Some Lifting up to 30 pounds JOB SPECIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Minimum Education: High school graduation or GED required. College degree and/or training in medical terminology preferred. Certification(s) Required: LOMA/ICA and HIAA coursework and Fraud Training Minimum Experience: Experience in claims processing, medical billing, insurance, or health services preferred. Familiarity with group health benefits preferred.
Other Qualifications: Excellent oral and written communication skills required. PC skills, including Windows and Word. Ability to learn all functions of the claims processing software as is necessary for claims processing and adjudication. Must be able to adapt to software changes as they occur.
Typing ability of 45 wpm net. Knowledge of medical terminology and basic health insurance concepts. Excellent listening skills. Basic mathematical skills.
High level of interpersonal skills to work effectively with others. Ability to organize and recall large amounts of detailed information. Ability to read, analyze and interpret benefit summary plan descriptions, insurance documents, plan benefits, and regulations and make appropriate applications to specific situations. Ability to meet productivity standards with 99% financial accuracy and 95% procedural accuracy.
Thorough knowledge of claims processing procedures and requirements. Ability to project a professional image and positive attitude in any work environment. Ability to comply with privacy and confidentiality standards. Ability to be flexible, work under pressure and meet deadlines.
Ability to analyze and solve problems with professionalism and patience, and to exercise good judgment when making decisions. Ability to operate typical office equipment. Working knowledge of general office procedures.
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