Healthcare Claims Examiner III

Position Summary

The Claims Examiner III is responsible for processing submitted electronic claims to ensure proper filing procedures and that processing guidelines and rules have been followed. The Claims Examiner III also validates claim or referral submissions to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.

• Conduct analysis around various claims payment processes to ensure accuracy of system configuration and provider payments.
• Investigate and resolve problem claims, while focusing on improving errors and problems to prevent future occurrences.
• Perform and execute various claims process testing requests to ensure desired results are met to support accurate claims payments.
• Analyze and adjudicate complex claims that cannot be auto adjudicated.
• Adjudicate claims by, including but not limited to, applying medical necessity guidelines, determining coverage and completing eligibility verification, identifying discrepancies and applying all cost containment measures.
• Process medical claims by approving or denying documentation, calculating benefits due initiating a payment or denial letter.
• Follow any center for Medicare and Medicaid (CMS) changes affecting claims processing.
• Perform pre-payment audit.
• Follow company policies, procedures and guidelines to ensure legal compliance.
• Update claims knowledge by participating in educational opportunities, whether system oriented or medical coding/terminology/interpretation.
• Update and maintain departmental and specialty network standards of operating procedure (SOP).
• Complies with performance standards as set forth by the department head.

• 6+ years of Claims Adjustment experience/ previous claims processing experience.
• Knowledge in Podiatry, Orthopedic, Dermatology and/or Pain Management specialties preferred.
• Knowledge of HIPAA policies and Compliance.
• Medical Terminology including ICD (10) and CPT Knowledge.
• Associates degree preferred

• Proficient in Microsoft Office programs.
• Previous experience with systems processing.
• Research skills