Medical Claims Examiner

CHS•Clearwater, FL

About The Position

Overview Health Insurance Medical Claims Examiner Monday-Friday Schedule with daytime hours Responsibilities Summary: The Medical Claims Examiner adjudicates medical claims based on health policy provisions and established guidelines. Essential Duties and Responsibilities: Reviews and adjudicates medical claims based on health policy provisions and established guidelines Requests additional information from members and providers as needed Initiates and completes claim investigations when indicated including pre-existing conditions, accidents, medical necessity and appropriateness, eligibility and coordination of benefits Documents fully claims referred to senior staff for review and determination Maintains company production and quality standards Participates in training Other Responsibilities: Adheres to the policies and procedures of Premier Administrative Solutions Maintains strict confidentiality of client, company and personnel information Demonstrates a strong commitment to the mission and values of the organization Adheres to company attendance standards Performs other duties as assigned Supervisory Responsibilities: None Competencies: Strong organizational and interpersonal skills Excellent written and verbal communication skills Detail oriented Ability to multi-task and work independently Knowledge of medical and dental coding systems Knowledge of medical terminology Qualifications Qualifications: Minimum two (2) years of medical claims processing experience - Payor/Carrier/TPA side Must have reliable and secure internet access and live in the state of FL Education and/or Experience: High school diploma or equivalent is required Certificates, Licenses, Registrations: None Computer Skills: Proficiency using software programs such as MS Word, ACCESS, PowerPoint, Excel and Outlook Environmental Factors/Physical Demands: Training is performed in an office environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds. PA123

Requirements

Strong organizational and interpersonal skills
Excellent written and verbal communication skills
Detail oriented
Ability to multi-task and work independently
Knowledge of medical and dental coding systems
Knowledge of medical terminology
Minimum two (2) years of medical claims processing experience - Payor/Carrier/TPA side
Must have reliable and secure internet access and live in the state of FL
High school diploma or equivalent is required
Proficiency using software programs such as MS Word, ACCESS, PowerPoint, Excel and Outlook

Responsibilities

Reviews and adjudicates medical claims based on health policy provisions and established guidelines
Requests additional information from members and providers as needed
Initiates and completes claim investigations when indicated including pre-existing conditions, accidents, medical necessity and appropriateness, eligibility and coordination of benefits
Documents fully claims referred to senior staff for review and determination
Maintains company production and quality standards
Participates in training
Adheres to the policies and procedures of Premier Administrative Solutions
Maintains strict confidentiality of client, company and personnel information
Demonstrates a strong commitment to the mission and values of the organization
Adheres to company attendance standards
Performs other duties as assigned