Claims Examiner I

Capital Health Plan•Tallahassee, FL

23h•Onsite

About The Position

Capital Health Plan is looking for a full-time Claims Examiner I to join our team in Tallahassee, FL. In this full-time role, you will help ensure insurance claims are reviewed, evaluated, and processed accurately according to departmental policies, provider agreements, and member benefits. As a Claims Examiner I, you will analyze insurance claims of low to moderate difficulty to determine Capital Health Plan's liability and adjudicate claims in accordance with departmental policies and provider agreements. Your day will include reviewing claims for errors or missing information, evaluating claims for payment based on provider agreements and member benefits, and issuing appropriate denial notifications when necessary. You will follow up on pending claims, work with other departments to resolve outstanding issues, maintain processing statistics, and notify the Claims Supervisor when pending claims exceed established limits. You will also perform data validation on scanned and OCR claims, enter information from paper claims, and refer questionable claims for further review. Success in this role will be measured by your ability to meet standards for production, accuracy, and customer service while progressing to more complex claims within six months.

Requirements

High school diploma or equivalent or one to three months of related experience and/or training or an equivalent combination of education and experience
Ability to read and interpret safety rules, operating and maintenance instructions, and procedure manuals
Ability to write routine reports and correspondence
Ability to communicate effectively with customers and employees
Basic math skills and ability to compute rates, ratios, and percentages and interpret bar graphs
Ability to carry out detailed written or verbal instructions
Ability to solve problems involving a few concrete variables in standardized situations
Knowledge of, or ability to learn, industry-standard procedure and diagnosis codes
Knowledge of, or ability to learn, medical terminology
Skilled in the use of, or ability to learn, Microsoft Outlook, Word, and Excel
Working knowledge of, or ability to learn, Adobe Acrobat software
Ability to meet and maintain state, federal, and CHP guidelines and standards for timeliness and accuracy of claims processing
Ability to read, understand, and interpret claim editing documentation and healthcare regulatory information
Ability to pass a background check and drug screening test

Nice To Haves

Progressing to more complex claims within six months

Responsibilities

Analyze insurance claims of low to moderate difficulty to determine Capital Health Plan's liability and adjudicate claims in accordance with departmental policies and provider agreements.
Review claims for errors or missing information.
Evaluate claims for payment based on provider agreements and member benefits.
Issue appropriate denial notifications when necessary.
Follow up on pending claims.
Work with other departments to resolve outstanding issues.
Maintain processing statistics.
Notify the Claims Supervisor when pending claims exceed established limits.
Perform data validation on scanned and OCR claims.
Enter information from paper claims.
Refer questionable claims for further review.