Claims Examiner I/II - Temporary
About The Position
This is a full-time temporary position. If selected, onboarding will be completed through a staffing agency. This position may be filled at the I or II level based on experience and qualifications. Health maintenance organization (HMO) (Payer) claims payment-processing experience is required. This position is responsible for claims auditing and payment functions for a Knox-Keene licensed health maintenance organization (HMO). Under management direction, responsible for reviewing and processing all types of medical and facility claims from contracting and non-contracting providers and from subscribers and enrollees for payment in an accurate and timely manner. Responsible for applying correct contract benefits, policies and procedures.
Requirements
- High School Diploma from an accredited school or equivalent.
- Up to (1-2) years of medical claim payment or medical billing processing experience.
- Experience investigating COB.
- Ability to calculate usual and prevailing fees.
- Health maintenance organization (HMO) claims payment-processing experience is highly desirable.
- Must have claims examiner experience as a payor.
- Computerized on-line data entry systems; organizational structure of medical claims processing; methods and procedures utilized in medical claims processing; medical terminology; CPT & ICD-9 coding; COB & subrogation investigation.
- Adapt to a rapidly evolving work environment; work independently; communicate with a variety of personnel and providers.
- Knowledge of: Computerized on-line data entry systems; organizational structure of medical claims processing; medical terminology; HCPCS, CPT & ICD-10 coding, UB04 and CMS1500 forms.
Nice To Haves
- Health maintenance organization (HMO) claims payment-processing experience is required
Responsibilities
- Resolve system suspended claims for PCPs, Labs, Radiology, less complicated specialists, and Physical Therapy.
- Deny inappropriate claims following policy guidelines.
- Prepare claims that must be routed to other departments for further review.
- Review difficult claims with guidance from Claims Supervisor.
- Identify billing errors and possible fraudulent claims submissions.
- Obtain eligibility verification and other health insurance coverage by Internet or POS.
- Responsible for correct manual calculation of benefits when applicable.
- Identify possible CCS eligible claims for further investigation.
- Report overpayment refund requests on SharePoint log.
- Maintain productivity and quality in accordance with established guidelines.
- Perform other job-related duties as required.
- Regular Predictable attendance.
- Adheres to all company policies and procedures relative to employment and job responsibilities.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
