Claims Examiner - Reside

Note: May be entitled to translation/bilingual, shift or other wage premiums as governed by the applicable collective bargaining agreement. Please refer to the respective collective bargaining agreement for additional information on such wage premiums: https://(Use the "Apply for this Job" box below)..

Through comprehensive assessment and analysis, adjudicates managed healthcare claims/bills, authorizations and referrals, for payment or denial within contract agreement and/or regulatory requirements. Performs these duties using industry standard knowledge of managed healthcare claim/bill payment processing and medical regulations, verifies and updates relevant data into various computerized internal and external systems.

• For all lines of business analyze claim holds/pends, research and track required claim information to adjudicate professional and hospital claims/bills.
• Proactive and/or responsive outreach to providers, members and other customers that could include phone calls, emails or other methods as needed.
• Proactively communicate with internal departments as appropriate to resolve claims issues promptly.
• Provides input to supervisor and training and development team regarding training and educational tools to enhance department production and processes.
• Provides assistance to prepare materials as needed to the leads, supervisors and managers for external audits.
• Communicate problems and/or trends to leads and management. Understand and apply county, state and federal regulations.
• Other duties as assigned within department job functions.

Experience

• Minimum three (3) years of claims adjudication experience required.

Education

• High School Diploma or General Education Development (GED) required.

License, Certification, Registration

• N/A

Additional Requirements

• Customer service experience.
• Basic PC skills required.
• Working knowledge of Microsoft Word.
• Ability to work in a Labor Management Partnership environment.
• Ability to understand and meet customer needs in a claims setting.
• Ability to apply procedures, practices and methods used in claims processing.
• Skills in analysis, interpretation and application of procedures, practices and methods used in claims adjudication without direct supervision or oversight.

Preferred Qualifications

• N/A