Senior Claims Examiner
About The Position
This position audits all claims for proper adjudication while handling special projects, reconsiderations, refunds and void processes. The incumbent will maintain proper record keeping of all support files and be responsible for providing in-service to appropriate personnel with regard to changes and updates in claims processing guidelines for the Banner and Risk Plans. This position may also be responsible for resolution of issues received from internal/external clients to include Customer Service, Provider Relations, Networks, Finance, Medical Management, etc. As a Senior Claims Examiner you will spend most of your day researching claims — auditing them for accuracy, compliance, and correct payment. You’ll manage escalated and complex claims issues, working closely with internal departments for reconsiderations, refunds and payment disputes. A big part of the role is reviewing emails for encounters, outside vendors, and special projects, while keeping everything moving on time across Medicare plans. You’ll also create reports to track trends and quality opportunities, support mass adjustment efforts, and act as a go-to subject matter expert when tricky claim questions come up. Overall, you’ll work independently within defined processes while providing strong leadership, accuracy, and great service every step of the way. This is a remote position is only for applicants who reside in the following states: Arizona (AZ), California (CA), Colorado (CO), Nebraska (NE), Nevada (NV), and Wyoming (WY). The work schedule is set for Monday to Friday, 8 hour shifts.
Requirements
- High school diploma/GED or equivalent working knowledge.
- A minimum of three to four years experience in Medical and/or Dental claims adjudication in an automated environment.
- Must have an excellent understanding of medical terminology, contract and benefit interpretation, CPT, HCPCS and ICD-9/ICD-10 coding with a working knowledge of Medicare, AHCCCS, Self-funded and/or commercial insurance plans.
- Must possess strong oral and written communication skills including effective interpersonal skills and attention to detail and accuracy.
Nice To Haves
- Previous claims auditing experience is preferred.
- Associates degree in related field.
- Additional related education and/or experience preferred.
Responsibilities
- Audits claims for accuracy of the data, payments, contract interpretation and compliance within established polices and procedures.
- Researches and processes adjustments for reconsiderations, refunds, voids, and special projects.
- Selects claims though random process to conduct audits to ensure compliance standards is met.
- Supports and assists with mass adjustment projects.
- Manages the claims administration workflow in a timely and accurate manner necessary to meet Plan requirements associated with the company Health, Risk and Dental Plan benefit process and/or requirements associated with AHCCCS, Medicare, and Commercial.
- Acts as the primary claims resolution specialist for internal and external clients related to escalated claims issues and for claims adjudication and handling of difficult claims issues.
- Provides information to providers/members and maintains system information as necessary for internal and external auditing purposes.
- Develops and creates reports necessary to track, trend and monitor for training and quality purposes, and workflow efficiencies.
- Works independently under regular supervision.
- Works within defined processes.
- Provides leadership requiring advanced subject matter knowledge.
Benefits
- Comprehensive benefit package
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
