Claims Examiner
Job Description
Analyze and adjudicate a variety of claim types to include facility, professional, inpatient, and outpatient services
Follow claims adjudication rules to assure that all claims are adjudicated in accordance with CMS rules and regulations and our Client's internal criteria
Review different lines of business to include Medicare, Medicaid, and Commercial services adherence to the contracts and timeliness guidelines
Authorize claim payments within established limits; otherwise forward to Claims Manager
Potentially process refunds appeals, disputes, and adjustments (when applicable);
Identify process improvement opportunities within the claim department and recommend system enhancements
Handles any additional responsibility which may be assigned
Requirements
Education :
High School Diploma or equivalent required
Experience :
Minimum of one-year experience working closely with health claims or in a claims processing/adjudication environment; required
An abundance of opportunities for promotion within for those looking for upward mobility
Meeting and exceeding metrics is rewarded
Technical Skills / Knowledge:
Understanding of health claims processing/adjudication
Ability to perform basic to intermediate mathematical computation routines
Medical terminology strongly preferred
Understanding of ICD-9 & ICD-10
Basic MS Office computer skills
Ability to work independently or within a team
Time management skills
Written and verbal communication skills
Attention to detail
Must be able to demonstrate sound decision-making skills
Other Skills Required
Ability to work independently or within a team
Time management skills
Written and verbal communication skills
Attention to detail
Must be able to demonstrate sound decision making skills