Medical Claims Examiner

The Senior Claims Examiner is responsible for reviewing, analyzing, researching, and resolving complex medical claims in accordance with claims processing guidelines and desktops, as well as, ensuring compliance with federal regulations. This role works in conjunction with Business Configuration, Network Management, Provider Data, Complaints, Appeals and Grievances as well as other operational departments to ensure validation and quality assurance of claims processing.

Meets expectations of the applicable OneCHRISTUS

Competencies:

Leader of Self, Leader of Others, or Leader of Leaders.

• Analyze medical claim information and take appropriate action for payment resolution in accordance with policies and procedures, desktops, processing guidelines, and federal regulations.
• Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc.
• Work claim projects resulting from over payments or underpayments related to manual processing errors, benefit updates, and/or contract, fee schedule changes.
• Process provider refunds, reconsiderations, and direct member reimbursements.
• Process medical claim adjustments, recovery of claim over payments, and execution of claim batch adjudication.
• Solve moderately complex claims and escape issues to the Claims Team Lead, Supervisor or Manager.
• Assist with database improvements and testing for system upgrades, conversions, or implementation of new processes