Claims Examiner

Advanced Medical Pricing Solutions•Phoenix, AZ

1d•Onsite

About The Position

The Claims Examiner properly applies plan/guidelines provisions. This position is responsible for processing medical, dental and vision claims, and answers questions in accordance with relevant terms and established procedure. This position works closely with other departments to proactively research concerns and resolve to the satisfaction of the client. This position will handle complex claims issues, assist with team workflow management and any special projects as assigned. This position maintains a comprehensive understanding of the plan document(s)/guidelines under their scope of responsibility.

Requirements

High school diploma or equivalent required
2 -5 years of Claims Examiner experience or equivalent required
Knowledge of medical terminology preferred

Nice To Haves

Associates degree in Medical Billing and Coding or related field preferred
Javelina a huge plus

Responsibilities

Maintain HIPAA/PII guidelines to ensure the confidentiality of all calls and documents
Claims Processing
Interpret plan documents/guidelines
Determine eligibility by reviewing, researching and analyzing information
Process, deny, allow or pend claims
Manage a moderate volume and complexity of groups and members
Use critical thinking and reasoning to manage workload with above average level of financial risk
Provide training to new and assigned employees
Correspondence
Maintain and enter information into system as information is received
Forward all records to the appropriate parties
Group Contacts
Record and respond to calls/e-mails from Groups
Maintain high level of knowledge to answer specific plan/guideline and claim questions
Establish relationships with Team Members for each group
Review issues as they arise
Appeals and Inquiries
Note system when appeals and inquiries are established
Record all information on appeals and inquiries in the database
Note in system if claim is going to a committee or to outside review
Customer Service
Serve as a role model in demonstrating core values of customer service
Provide timely and thorough responses to internal and external customers
Respond to member and group correspondences regarding plan/guideline or claim questions within 24 hours
Escalate difficult issues to the appropriate chain of command
Quality Assurance
Ensure compliance with service standards
Follow trends within assigned scope and alert appropriate parties of any that fall outside quality parameters
Develop and execute plans to meet established goals
Provide continuous feedback to strengthen and optimize quality performance
Work cross-departmentally to improve or streamline procedures
Maintain up to date knowledge on industry trends and look for new data sources
Develop or improve current internal processes to improve overall quality
Special projects as assigned