Specialty Claims Examiner

About the position Evaluate claims and determine payment or denial according to plan provisions, medical policy, and guidelines. Process claim payment thoroughly, attend all training, and refresher courses. Maintain clear claim notes, benefit quote documentation, thoroughly review patient and family notes. Maintain multiple network access for pricing and authorization to avoid inactivity and disruption for processing. Establish and maintain COB files, determine other coverage according to regulatory and plan requirements. Applies COB payments for final claim payment. Research and determine proper CPT procedure and ICD-10 Diagnosis Codes. Research and respond to written correspondence from participants, providers, and local unions/employers. Transfer claims to Benefit Review for processing instructions and or other departments according to guidelines. Work effectively to achieve at a minimum production, quality, and accuracy standards. Display maturity, composure and ability to operate under stress conditions. Follow department policy and procedures distributed. Attend mandatory department meetings as scheduled. Assist other department areas as required dependent on workload and inventory needs. Excellent organization and assignment management skills. Clear communication with internal and external customers. Ability to Navigate in external network pricing platforms. Ability to prioritize workload and adhere to network administrative agreements. Maintains professionalism at all times. Perform other duties as assigned.

Responsibilities

• Evaluate claims and determine payment or denial according to plan provisions, medical policy, and guidelines.
• Process claim payment thoroughly, attend all training, and refresher courses.
• Maintain clear claim notes, benefit quote documentation, thoroughly review patient and family notes.
• Maintain multiple network access for pricing and authorization to avoid inactivity and disruption for processing.
• Establish and maintain COB files, determine other coverage according to regulatory and plan requirements.
• Applies COB payments for final claim payment.
• Research and determine proper CPT procedure and ICD-10 Diagnosis Codes.
• Research and respond to written correspondence from participants, providers, and local unions/employers.
• Transfer claims to Benefit Review for processing instructions and or other departments according to guidelines.
• Work effectively to achieve at a minimum production, quality, and accuracy standards.
• Display maturity, composure and ability to operate under stress conditions.
• Follow department policy and procedures distributed.
• Attend mandatory department meetings as scheduled.
• Assist other department areas as required dependent on workload and inventory needs.
• Maintain professionalism at all times.
• Perform other duties as assigned.

Requirements

• High school diploma or equivalent.
• Eighteen (18) months experience as a Claims Processor or similar function.
• Must have a broad knowledge of medical terminology and must possess excellent written and oral communication skills.
• Must possess good judgment skills and ability to interpret Department guidelines and contractual benefits.
• Working knowledge of DHPR and CMS rules for Claim Submission Claim Payment Eligibility Coordination of Benefits Primary / Secondary.
• Experience with Claims and Enrollment systems; COB validation; Understanding of primary secondary coverage rules.
• Must be proficient in excel.
• Excellent organization and assignment management skills.
• Clear communication with internal and external customers.
• Ability to Navigate in external network pricing platforms.
• Ability to prioritize workload and adhere to network administrative agreements.

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