Job Openings >> Claims Examiner I
Claims Examiner I
Summary
Title:Claims Examiner I
ID:1097
Department:Finance
Description

Job Summary:  The Claims Examiner I is responsible for processing claims for payment or denial to include detailed assignment including validation of claims for accuracy and completeness, confirmation of member eligibility, and verification of claim pricing and authorization to ensure service appropriateness.


Responsibilities

Processes claims timely for payment or denial with detailed assignment.

Validation of claims for accuracy and completeness.

Verification of claim pricing and authorization to ensure service appropriateness.

Support claim issues and projects, where they will investigate and resolve claims processing discrepancies with both internal and external business partners.

Refer questionable claims/ claim patterns appropriately for escalation.

Identifies and shares process, procedure, and systemic training opportunities.

Successful in meeting department production and quality standards and goals. 

Acts with honor and integrity

Performs other duties as assigned.

 

Educational & Experience Requirements

  • Associate's degree in a related field or equivalent relevant work experience with knowledge of medical terminology, health insurance plans, medical billing concepts.
  • 1-2 years of experience in a managed care, medical claims environment.
  • Previous experience in production environment preferred.

Language Skills

  • Ability to read and communicate effectively in English.
  • Additional languages preferred.

Skills

  • Basic computer knowledge such as Word and Excel.
  • Excellent customer service and follow-up skills.
  • Data entry and basic calculations.
  • Self-starter with ability to work independently.
  • Ability to sit for extended periods and read monitors.
  • Strong attention to detail.

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