The claims examiner is responsible for accurate and timely adjudication of claims for the Health Plans lines of business. Primary duties include analysis and resolution of claims, including coding principles, benefits, pricing, and potential third-party liability. The claims examiner must be able to work independently, effectively prioritizing work in a production environment that frequently changes to meet production standards and contractual requirements. The Claims Examiner must maintain production and inventory standards compliant with Claims Administration requirements. Success in this position will be based on the individual's ability to effectively prioritize work, identify, and resolve complex concerns in a professional manner, and work in a team environment to achieve and maintain production and inventory standards.
-Timely and accurate adjudication of all types of claims from assigned workflow queues.
-Compliance with state, federal and contractual requirements to Claims Administration.
-Performance standards of 15 claims/hour with 98% or above financial and procedural quality & accuracy rates.
-Demonstrate a thorough knowledge of the Plan's claims processing procedures as provided in training materials and proficiency with the core and ancillary system applications.
-Demonstrates the ability to think analytically to resolve complicated claim issues and identify appropriately when to escalate issues for review.
-Demonstrates a thorough knowledge of regulatory requirements, individual plan benefits, provider contracts, policies, and procedures for product assignment.
-Claim analysis of coding and billing compliance, potential third-party liability, accurate coordination of benefits (COB), benefit application including limitations and restrictions, pre-existing conditions, subrogation, medical necessity and other claim investigation as appropriate.
-Accurate and timely review of claim pricing to facilitate manual pricing as necessary, working with various Health Plan provider networks.
-Complete all mandatory claims training/refresher courses.
-Effectively communicates with members and providers verbally and in writing regarding claim issues including claim adjudication, subrogation, and overpayments or billing problems.
-Actively participates and supports department and organization-wide efforts to improve efficiencies while supporting departmental goals and objectives.
-Complete all mandatory compliance and corporate training.
-Must be able to adapt to a changing work priorities and requirements and perform other duties as directed to support the overall functions of Claims Administration and support of staff without boundaries within the Plan.
-High school diploma or equivalent required.
-Must have 3 years of relevant claim processing experience in insurance/healthcare industry(insurance, managed care or TPA Company) to support our clients.
-Must have recent (within 5 years) claims experience with Medicare, Medicaid,vclaims and adjustments on Amisys claim system.
-Possess high productivity and quality standards within a claims processing automation environment
-Knowledge of CPT, HCPC, ICD-9, ICD-10 codes
-Knowledge of HMO, PPO Medicare and Medicaid plans, as well as experience with Medicare Part D
-Knowledge of Medical terminology
- Knowledge of HealthRules System Software (HealthEdge) Required
The Company is an equal opportunity employer and makes employment decisions on the basis of merit and business needs. The Company will consider all qualified applicants for employment without regard to race, color, religious creed, citizenship, national origin, ancestry, age, sex, sexual orientation, genetic information, physical or mental disability, veteran or marital status, or any other class protected by law. To comply with applicable laws ensuring equal employment opportunities to qualified individuals with a disability, the Company will make reasonable accommodations for the known physical or mental limitations of an otherwise qualified individual with a disability who is an applicant or an employee unless undue hardship to the Company would result.
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