Claims Examiner

South Florida Community Care Network•Sunrise, FL

18h•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 Claims Examiner adjudicates and enters claims across all lines of business, applies benefit plan designs and regulatory standards, and reviews coverage, coding, medical review determinations, billing discrepancies, and cost-containment measures. The role also researches complex claims, disputes, and appeals; identifies questionable claims and coordination-of-benefits issues; and works with Claims Analysts and other departments to support accurate, timely payment decisions. The position requires maintaining department quantity and quality goals, reviewing production reports, and participating in side-by-side and peer training. The employee may also assist with projects and clerical support, and may be assigned other job-related duties 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. The work may take place inside or outside the office and may involve travel to other offices and domestic travel. Candidates selected must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

Requirements

High school diploma or General Education Diploma (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.
Thorough knowledge of coding structures, including CPT, HCPCS, Revenue codes, ICD-10, and DRG.
Knowledge of coordination of benefits and familiarity with benefits and benefit calculations.
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 such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.
Ability to apply concepts of basic algebra and geometry.
Ability to work independently and meet deadlines.
Ability to maintain a good rapport and cooperative working relationship with the team.
Ability to speak effectively before groups of customers or employees of the organization.
Ability to apply common-sense understanding to carry out instructions furnished in written, oral, or diagram form.
Ability to deal with problems involving several concrete variables in standardized situations.
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 preferred.

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.
Understand and manually calculate claims 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 production reports daily for quality and training purposes.
Meet department quantity and quality goals for claims entered and accuracy percentages.
Complete side-by-side and peer training as needed.
Assist with projects and clerical support as needed.
Perform other job-related duties assigned by a supervisor or management.