Healthcare Claims Examiner

Allied Benefit Systems•Chicago, IL

9h•Remote

About The Position

The Claims Examiner determines whether medical claims should be paid and, if so, the appropriate payment amount. This requires applying knowledge of each client’s customized group health plan and independently analyzing claims for cost reasonableness, medically unnecessary treatment, fraud, benefit eligibility, and the applicable level of benefits. The examiner may negotiate discounts with providers and authorize full payment, partial payment, or denial based on the investigation and analysis. The role includes reviewing claim documentation and coding, contacting providers, consulting with other entities, and documenting findings in systems including QicLink, Access, and alliedbenefit.com. The examiner also reviews suspended claim reports, follows up on unresolved issues, supports team members, and attends required continuing education, including privacy and security training. This is a remote desk role involving extended sitting and computer work. A cable broadband or fiber-optic internet connection with at least 100 Mbps download and 25 Mbps upload speed is required.

Requirements

High school diploma or equivalent work experience; college and advanced degrees are preferred.
At least 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 all areas affecting group health and welfare plans is required.
Cable broadband or fiber-optic internet service with at least 100 Mbps download and 25 Mbps upload speeds.
Ability to perform extended periods of sitting and computer work.

Nice To Haves

College degree or advanced degree.

Responsibilities

Independently review and analyze healthcare claims for reasonableness of cost, medically unnecessary treatment, and fraud.
Determine whether a health plan provides benefits for a submitted claim and the level of benefits payable to the provider.
Contact providers to negotiate discounts.
Log negotiated claims in the Access database and create 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 needed.
Consult with other entities that can provide additional claim evaluation.
Process claims in the QicLink System; review and analyze them and add applicable notes.
Document gathered information 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 and when requested.
Attend required continuing education classes, including HIPAA training.
Perform other duties as assigned.