Healthcare Claims Examiner - Remote

Allied Benefit Systems•Chicago, IL

2d•$50,000 - $50,000•Remote

About The Position

The Claims Examiner determines whether medical claims should be paid and, if so, the proper payment amount under group health plans. The role applies knowledge of each client’s customized plan terms and conditions and independently investigates claims for cost reasonableness, medically unnecessary treatment, and potential fraud. The position is remote and requires a cable broadband or fiber-optic internet connection with minimum speeds of 100 Mbps download and 25 Mbps upload. The examiner evaluates coverage and benefit levels, negotiates discounts with providers, reviews supporting records and coding, and documents claim findings in the relevant systems. The role also supports colleagues, completes required continuing education, and performs other duties as assigned.

Requirements

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 areas affecting group health and welfare plans is required.
High school diploma or equivalent work experience required.
Ability to use a cable broadband or fiber-optic internet connection with at least 100 Mbps download and 25 Mbps upload.

Nice To Haves

College or advanced degrees are preferred.

Responsibilities

Independently review and analyze health care claims for cost reasonableness, medically unnecessary treatment, and potential fraud.
Determine whether claims are covered under a health plan and the level of benefits payable to providers.
Contact providers to negotiate discounts; log negotiated claims in the Access database and prepare weekly summary reports.
Review and understand the terms and conditions of clients’ customized plans.
Comply with applicable privacy and security laws, including HIPAA and HITECH.
Request, review, and analyze physician notes, hospital records, and police reports as applicable.
Consult with other entities that can provide additional claim evaluation.
Process claims in the QicLink System and review, analyze, and add applicable notes in that system.
Document information gathered in available systems, including QicLink and alliedbenefit.com.
Review billed procedure and diagnosis codes for billing irregularities and analyze claims for billing inconsistencies.
Review and analyze procedure and diagnosis codes for medical necessity.
Authorize payment, partial payment, or denial based on individual investigation and analysis.
Review Suspended Claim Reports and follow up on open issues.
Assist and support other team members as needed or requested.
Attend required continuing education classes, including HIPAA training.
Perform other duties as assigned.