Claims Examiner III
Claims Examiner III
JOB SUMMARY:
Position is responsible for independently reviewing, adjudicating and finalizing Provider Dispute Resolution (PDR) requests, processing claims adjustments requests received from Customer Service, and adjudicating special projects claims. Research and review necessary documentation and apply claims policy appropriately and accurately in order to resolve and finalize claims adjustment requests. Process professional and institutional electronic and paper medical claims. Meet established Claims department claims processing quality and production performance benchmarks. Effectively manage workload and prioritize assignments. Work without significant guidance. Ensures claims adjudication is in accordance with State, Federal and Health plan regulatory requirements as well as departmental guidelines.
MAJOR DUTIES AND RESPONSIBILITIES:
- Responsible for reviewing, analyzing, and finalizing PDR requests in accordance with departmental, health plan, and regulatory timeliness and accuracy standards.
- Responsible for reviewing, analyzing, and finalizing Customer Service claims adjustment requests in accordance with departmental, health plan, and regulatory timeliness and accuracy standards.
- Assist with special projects, to include review and adjustment of special project claims.
- Utilizes appropriate reference materials and policies to research information, respond to inquiries, resolve problems/issues and process claims accurately.
- Review CAP deduct issues and investigate/resolve Medicare Secondary Payer requests.
- Process medical claims on an as needed basis.
- Meet established departmental quality, production, and turnaround time performance benchmarks.
- Acknowledge and understand all information discussed at staff meetings and fully comprehend updates and in-service training.
- Manage and maintain workflows and assignments and perform duties with reasonable independence.
- Make significant contributions to the work team and demonstrates full competence in own work area.
- Accepts and performs other duties as assigned.
QUALIFICATIONS:
EDUCATION AND/OR TRAINING: High school graduate. Knowledge of and working experience with ICD-9, CPT and HCPC coding systems. Thorough knowledge of medical terminology, enrollment and membership activities and claim processing procedures/systems. Basic understanding of Microsoft Word and Excel applications.
SKILLS AND ABILITIES: Ability to work independently, organize, and prioritize work assignments. Independent decision making skills and demonstrate initiative to resolve issues. Excellent oral and written communication skills, great organizational skills and ability to prioritize projects. Ability to exercise good judgment and handle a fast paced environment. Able to assess and coordinate departmental work flows effectively. Ability to process all types of medical claims and interpret authorizations, contracts and physician reimbursement methodologies.
EXPERIENCE: Five (5) years prior claims processing experience in an IPA or HMO related setting. Prior experience with claims adjustments and PDR’s preferred.