Claims Examiner I

Florida Blue • United States,

6h • Onsite

About The Position

As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity.

Requirements

• 2+ years related work experience.
• Medical claims and adjudication experience on a computerized claims payment system in the healthcare industry.
• High school diploma or GED
• Knowledge of medical coding, CPT, ICD10, COBRA, HIPAA, pre-existing conditions, and coordination of benefits.
• Experience with multiple surgical procedures and establishment of reasonable and customary fees.

Nice To Haves

• Medical billing and coding courses are a plus.
• Experience in processing all types of medical claims helpful.

Responsibilities

• Day-to-day processing of claims for accounts
• Responsible for processing of claims (medical, dental, vision, and mental health claims)
• Claims processing and adjudication.
• Claims research where applicable.
• Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic).
• Incumbents are expected to meet and/or exceed qualitative and quantitative production standards.
• Investigation and overpayment administration
• Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers.
• Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records.
• Utilize systems to track complaints and resolutions.
• Resolving claims appeals, researching benefits, verifying correct plan loading.

Benefits

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, Short- and long-term disability programs
• Leave programs to support personal circumstances.
• Retirement Savings Plan includes employer contribution and employer match
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available and a comprehensive wellness program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED