Claims Examiner Jobs

About The Position

Requirements

• High school diploma or equivalent.
• Strong knowledge of professional and institutional claim processing procedures, including COB (Coordination of Benefits), TPL (Third Party Liability), and WC.
• Familiarity with CPT, HCPCS, ICD-10, ASA, Revenue Codes, and related coding.
• Ability to perform high-volume data entry.
• Strong background with system automation of claims processes and workflows.
• Familiarity with office equipment, including a photocopy machine, scanner, and facsimile machine.
• Proficiency in MS Excel, Word, and Outlook.
• Ability to type 40–50 words per minute (WPM) or 6,000–8,000 keystrokes per hour (KSPH).
• One or more years of experience working in a healthcare or other related business environment.

Nice To Haves

• Experience in medical billing services and/or a managed care environment.

Responsibilities

• Follow written criteria, policies, and procedures to thoroughly review and process claims.
• Evaluate claims for payment appropriateness based on eligibility, benefits, authorizations, coding, compliance, contracted payment terms or fee schedules, and health plan contracts.
• Stay informed about annual contract changes and apply the correct terms to claims.
• Process denials accurately in the system so the correct letters are generated.
• Meet internal, external, and governmental timeliness standards for claims processing.
• Make decisions regarding payment or denial of medical services while handling sensitive and confidential information discreetly.
• Refer claims and supporting documentation to the Utilization Management (UM) department when they do not align with department policy guidelines.
• Work with Eligibility, Member Services, UM, providers, Health Plans, and applicable staff to resolve claims.
• Meet established production and quality standards for accuracy and efficiency.
• Work independently on assigned tasks under established policies and procedures.
• Perform other related duties as assigned.

Benefits

• Medical insurance
• Dental insurance
• Vision insurance
• Paid Time Off (PTO)
• Floating Holiday
• Simple IRA Plan with a 3% employer contribution
• Employer-paid life insurance
• Employee Assistance Program