Claims Examiner will be responsible for adjudicating complex claims, manually and/or automatically priceclaims accurately, and identify billing issues.
Responsibilities include, but not limited to:
- Analyze, research, and process and/or adjust claims with accurate use of procedures and ICD-9 codes under respective provider and member benefits based on:
- Contractual agreement
- Health Plan division of financial responsibility
- Applicable regulatory legislature
- Claims processing guidelines
- Client group’s and company’s policies and procedures
- Review and process facility (UB-04) and professional (CMS-1500) claims.
- Process Medicare member claims based on DMHC and DHS regulatory legislature
- Respond and resolve providers’ and health plans’ inquires in a timely manner
- Review services for appropriate charges and apply authorization
- Monitor aging claims with reports to maintain timeliness
- Maintain quality and productivity standards
- Participate in special projects
- Works closely with Supervisor and reports any issues
• Bachelor’s degree in related field or AA degree with related experience
• Must have at least 3 years of applicable healthcare claims adjudication experience within a managed care industry
• Must be familiar with ICD-9, HCPCS, CPT coding, APC, ASC, and DRG pricing.
• Must be familiar with facility and professional claim billing practices.
• Must have good written and communication skills.
• Must be able to follow guidelines, multi-task, and work comfortably within a team-oriented environment.
• Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and EZ-CAP. Crystal Report is a plus.
• Typing skills of at least 40 wpm.