Insurance Claims Examiner II

Forest County Potawatomi Community•Crandon, WI

About The Position

This position involves analyzing and processing insurance claims to determine plan liability. The role requires reviewing various types of claims, including Purchased Referred Care, medical, dental, and vision. Responsibilities include compiling and tracking claims for reimbursement, collaborating with the Eligibility team, and assisting with research and development projects. The role also involves obtaining necessary certifications, providing training to staff, and responding to formal appeals. Additionally, the position requires reviewing and resolving claims appeals, managing vendor relationships, identifying potential subrogated recovery, and ensuring claims adjudication complies with all standards and protocols. A key aspect of the role is reviewing claims for possible abuses and/or fraud and bringing them to the attention of management.

Requirements

High School Diploma or GED
Five (5) years of experience in medical claims processing
Three (3) years in customer service
Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards
Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology
Knowledge of insurance principles and/or procedures
Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment
Must successfully pass all applicable background checks and drug screens

Nice To Haves

Provides training and guidance through expert knowledge of claims administration and adjudication to Insurance Department staff; responsible for the timely response to formal appeals from members, employees, clients and providers.
Works with the Customer Service Coordinator to manage and provide direction to the utilization review and case management vendor; identifies and manages claims with potential subrogated recovery.
Oversees the repricing processes to ensure the integrity of the product; investigates claims referred by staff for possible abuse and fraud.

Responsibilities

Analyzes and processes a minimum of 200 claims daily to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims.
Compiles, submits documents, and tracks claims for CHEF (Catastrophic Health Emergency Fund) for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations.
Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments.
Assists with other research and development projects as directed by Management; obtains and maintains necessary certification for Health Insurance Marketplace CAC.
Reviews, resolves and/or escalates Level 2 claims appeals; releases claims up to the designated draft authority for Level 2 Claims Examiner.
Ensures that claims adjudication complies with all FCPID standards and protocols; reviews claims for possible abuses and/or fraud and bring to the attention of management.