Senior Examiner, Claims

Job Title

Provides senior level support for claims examination activities including evaluation of adjudication of claims to identify incorrect coding, abuse and fraudulent billing practices, waste, over payments, and processing errors.

• Evaluates the adjudication of claims using standard principles, and state-specific regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, over payments, and claims processing errors.
• Manages a caseload of claims - procures all medical records and statements that support the claim.
• Makes recommendations for further investigation and/or resolution of claims.
• Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication, and recommends solutions to resolve issues.
• Identifies and recommends solutions for error issues as it relates to pre-payment of claims.
• Monitors the medical treatment of claimants; keeps meticulous notes and records for each claim.
• Manages a caseload of various types of complex claims - procures all medical records and statements that support the claim.
• Meets state and federal regulatory compliance regulations on turnaround times and claims payment for multiple lines of business (LOBs).
• Meets department quality and production standards.
• Supports all claims department initiatives to improve overall efficiency.
• Completes claims projects as assigned.

• At least 2 years of experience in claims, and/or customer service experience in a clerical role - preferably in a managed care setting, or equivalent combination of relevant education and experience.
• Research and data entry skills.
• Organizational skills and attention to detail.
• Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
• Customer service experience.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

• Health care claims/billing experience.