Senior Examiner, Claims(Florida)
About The Position
The Senior Examiner, Claims provides senior-level support for claims examination activities. The role evaluates claims adjudication to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors, using standard principles and state-specific regulations. The examiner manages a caseload of claims, obtains supporting medical records and statements, monitors claimants’ medical treatment, and maintains detailed notes and records. The position recommends claims for further investigation or resolution and identifies and recommends solutions to reduce pre-payment errors. It also supports regulatory compliance, department quality and production standards, claims initiatives, and assigned projects.
Requirements
- At least 2 years of experience in claims and/or customer service in a clerical role, preferably in a managed care setting, or an equivalent combination of relevant education and experience.
- Research and data entry skills.
- Organizational skills and attention to detail.
- Time-management skills and the ability to manage simultaneous projects and tasks to meet internal deadlines.
- Customer service experience.
- Effective verbal and written communication skills.
- Proficiency with Microsoft Office suite and applicable software programs.
Nice To Haves
- Health care claims/billing experience.
Responsibilities
- Evaluate claims adjudication using standard principles and state-specific regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and claims processing errors.
- Manage a caseload of claims, including complex claims, and procure supporting medical records and statements.
- Recommend claims for further investigation and/or resolution.
- Identify adjudication and pre-payment error issues, oversee efforts to reduce defects, and recommend solutions.
- Monitor claimants’ medical treatment and maintain meticulous notes and records for each claim.
- Meet state and federal regulatory requirements for turnaround times and claims payment across multiple lines of business.
- Meet department quality and production standards.
- Support claims department initiatives to improve overall efficiency.
- Complete claims projects as assigned.
Benefits
- Competitive benefits and compensation package.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
No Education Listed
