Claims Examiner-Product

Allied Benefit Systems•Chicago, IL

18d•Remote

About The Position

The Claims Examiner is responsible for determining the proper payment (if any) of medical claims by group health plans, based upon specific knowledge and application of each client’s customized plan(s).

Requirements

Must have a minimum of 5 years of medical claims analysis experience (including dental and vision claims analysis).
Strong analytical skills
Knowledge of computer systems and CPT and ICD-9 coding terminology.
Continuing education in all areas affecting group health and welfare plans is required.

Nice To Haves

College and Advanced Degrees Preferred or equivalent work experience required.

Responsibilities

Independently review and analyze health care claims for: 1) reasonableness of cost; 2) medically unnecessary treatment by physicians and hospitals; and 3) fraud.
Determine whether a health plan provides benefits in connection with the claim submitted and the level of benefits to be paid to the provider.
Contact providers to negotiate discounts.
Log claims negotiated in Access database and create weekly summary reports.
Review and understand the terms and conditions of each clients’ customized plans.
Understand and comply with all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
Request, review and analyze any physician notes, hospital records or police reports.
Consult with other entities who can offer additional evaluation of a claim.
Process claims in the QicLink System.
Review, analyze and add applicable notes to the QicLink System.
Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com.
Review billed procedure and diagnosis codes on claims for billing irregularities.
Analyze claims for billing inconsistencies.
Review and analyze specific procedure and diagnosis codes for medical necessity.
Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
Review Suspended Claim Reports and follow up on open issues.
Assist and support other team members as needed and when requested.
Attend continuing education classes as required, including but not limited to HIPAA training.
Other duties as assigned.