Claims Examiner

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Doral, FL, US

6 days ago Requisition

Salary Range: $19.00 To $23.00 Hourly

To perform this job, an individual must perform each essential function satisfactorily, with or without a reasonable accommodation; including, but not limited to:

• Configure,implement and administer a robust claims quality and auditing program
• Establish best practice claims paymentmethodologybased on current CMS claims payment regulations
• Conduct root cause analysis on systemic issues; formulate action plan to avoid incorrect payment through review of contracts, Medicare claims payment rules, internalsystemand beneficiary impact
• Coordinate with Network Services and Provider Relations teams to ensure proper reimbursements
• Work closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment
• Conduct pre-pay and post-pay audits to verifyaccurateclaim payments and/ordenials
• Provide exceptional service to providers, internal and external customers in accordance with Company values
• Forecast all staffing requirements; schedule workforce accordingly
• Complete regular review of internal reporting (ex., high dollar claims)
• Ensure regulatory compliance,qualityandefficiency
• Participate and support ad-hoc audits as required
• Collaborate with Utilization Management Team as necessary
• Complete all assigned claim projects

• Effective supervision, including hiring, training, scheduling, workallocationand problem resolution
• Responsible for performance evaluation of team members and making recommendations for appropriate action, as well as motivating team members to achieve peak performance and productivity
• Continuing education and development of team members to adapt to sales deviations and business restructuring
• Maintain a reliable staffing model to ensure appropriate staffing levels

• Strong working knowledge of claims processing standards, CMS claims processing requirements and various Medicare fee schedules
• Knowledge of automated claims processing systems and other complex claim processing rules and regulations
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to Health Plan operations

• 2 years’ experience with complex claims processing and/or auditing within the health insurance industry or medical healthcare delivery system
• 2 years’ experience in a managed healthcare environment related to claims processing/auditing, including Medicare plans
• 2 years’ experience with CMS requirements, and other complex claim processing rules and regulations
• 2 years’ experience using Healthcare Common Procedure Coding Systems (HCPCS), CPT, ICD, Medicare codes
• Recent Institutional and Professional claim payment experience

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The noise level in the work environment is usually moderate.
• Works inthe field
• Interacts with patients, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lift, and moves intermittently during working hours.

Work schedule is approximate and hours/days may change based on…