Claims Examiner

South Florida Community Care Network LLC•Sunrise, FL

12h•$20 - $25•Hybrid

About The Position

Responsible for the accurate and timely adjudication of health insurance claims in accordance with established production and quality department standards. The role processes claims across all lines of business, reviews coverage, coding, medical review determinations, billing discrepancies, and cost-containment measures, and researches complex claims, disputes, and appeals to support accurate payment decisions. The position also supports quality and training through daily production reports, peer training, and maintaining department quantity and quality goals. Additional job-related duties may be assigned by a supervisor or management. Community Care Plan currently follows a hybrid work schedule and reserves the right to change schedules based on company needs. Candidates selected for the role must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

Requirements

High school diploma or GED and two to four years of related experience and/or training, or an equivalent combination of education and experience.
Knowledge of word processing software, spreadsheet software, internet software, and Epic software.
Knowledge of coding structures, including CPT, HCPCS, revenue codes, ICD-10, and DRG.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write routine reports and correspondence.
Verbal and written communication skills.
Ability to perform arithmetic calculations and calculate figures and amounts, including discounts, interest, commissions, proportions, percentages, area, circumference, and volume; ability to apply basic algebra and geometry.
Ability to work independently, meet deadlines, and maintain a cooperative working relationship with the team.
Ability to speak effectively before groups of customers or organization employees.
Ability to apply common-sense understanding to instructions provided in written, oral, or diagram form and to address problems involving several concrete variables in standardized situations.
Ability to meet the physical demands of the role, including sitting, using hands, reaching, talking or hearing, and occasionally lifting or moving up to 15 pounds.
Must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse if selected.

Nice To Haves

Medical Coding Certification, CPC or equivalent.

Responsibilities

Adjudicate and enter claims for all lines of business according to benefit plan designs and regulatory standards, including medical and behavioral health claims and benefits.
Review claims based on coverage benefits, coding guidelines, medical review determinations, billing discrepancies, and cost-containment measures.
Identify third-party or coordination-of-benefits issues and notify designated COB personnel for timely review and resolution.
Apply knowledge of COB, benefits, and benefit calculations.
Understand and manually calculate claim pricing, including Medicaid, Medicare, and UCR (Usual, Customary and Reasonable).
Identify inappropriate or questionable claims and refer them to Claims Analysts for review.
Research complex claims, disputes, and appeals thoroughly and make timely, accurate payment decisions, with input from Claims Analysts for quality assurance.
Process claim corrections and COB updates through the interdepartmental customer relationship management process.
Generate and review daily production reports for quality and training purposes.
Maintain department quantity and quality goals for claims entered and accuracy percentages.
Complete side-by-side and peer training as needed for educational opportunities.
Assist with projects and clerical support as needed.
Perform other job-related duties assigned by a supervisor or management.