Job Description Summary

The Claims Examiner I reports to the Superviosr of Claims. Claims Examiner I is responsible for reviewing and processing medical, dental, vision and electronic claims in accordance with state, federal and health plan regulatory requirements, department guidelines, as well as meet established quality and production performance benchmarks to include research and review of applicable documentation. The incumbent will also process Health Insurance Payment Demand (HIPD) claims. 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.

Qualifications

• High school education or equivalent: minimum one (1) to three (3) years year of experience as a Health Claims Examiner or comparable industry experience preferrecd.
• A minimum of one (1)year experience as a Claims Examiner for medical, dental claims and vision, subrogation, and accident claims
• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination
• Basic knowledge of medical terminology. Familiar with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
• Good verbal and written communication skills.
• 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.
• Ability to work under pressure and adapt to changing environment
• Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines.

Duties And Responsibilities

Claims Processing & Quality Assurance

• Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, 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.
• Analyze patient and medical information 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.
• Resolve benefit and eligibility issues that require detailed knowledge, support for customers within the claims processing, Company and ERISA guidelines. Process low level claims, re-pricing corrections.
• Research and complete all correspondence related to electronic and paper claims as
• 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.
• Meet and maintain individual and department productivity and quality standards.

Problem Solving, Judgement & Compliance

• Examine a problem, set of data or text and consider multiple sides of an issue, weighs consequences before making a final decision.
• Ensure compliance with all appropriate policies and practices, local, State, Federal regulations and requirements regarding claims and contract administration.
• Partner with peers to document and analyze functional requirements, identify gaps and alternative approaches to resolve problems.
• Contribute to defining and documenting standards and periodically reviewing them to integrate appropriate industry standards.
• Alert supervisors to potential higher risk compliance issues
• Make timely and effective decisions based on available information
• 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.
• All other duties as assigned.

Physical Demands/Work Environment

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.