Claims Examiner III
Employee Benefit Management Services, Inc. Billings, MT
- Expired: over a month ago. Applications are no longer accepted.
This position properly applies plan provisions on self-funded groups. This position is responsible for claims processing of medical, dental and vision claims, and answers questions in accordance with relevant terms and established procedure. This individual works closely with other departments to proactively research concerns and resolve to the satisfaction of the client. This individual may take on special projects as assigned, handle complex claims issues and assist with team workflow management. This position maintains a comprehensive understanding of the plan document(s) under their scope of responsibility.
Essential Duties and Responsibilities:
- Claims Processing
- Interprets plan documents.
- Reviews, researches, and analyzes information to determine eligibility.
- Processes, denies, pends, or allows claims.
- Utilizes void/refund function to reprocess designated claims.
- Is assigned new groups to EBMS and works with the new group implementation team on successful set-up.
- Manages a higher than average volume and complexity of medical lives and groups.
- Uses advanced thought and reasoning to manage workload that carries a high level of financial risk.
- Trains and mentors other employees as assigned.
- Accurately notes the system of all information received.
- Forwards all records.
- Group Contacts
- Tracks and returns calls and e-mails.
- Answers specific plan and claim questions.
- Knows each Team Member for each group.
- Goes over review issues.
- Appeals and Inquiries
- Notes system when appeals and inquiries are received.
- Records all information on appeals and inquiries in the database.
- Notes system if notified that claim is going to outside review or committee
- Customer Service
- Acts as a role model in demonstrating the core values in customer service delivery.
- Provides timely and thorough follow up with, internal and external customers.
- Tracks and returns telephone calls/mail to members and groups answering specific plan/claim questions within 24 hours
- Appropriately escalates difficult issues up the chain of command.
- Participates in mentor programs, advisory committees, process improvement and quality initiatives, job cross-training and leadership training.
- Provides back-up to the department and specialized functions as needed.
- Quality Assurance
- Ensures team compliance with service standards
- Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction.
- Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters.
- Performs self quality monitoring in order to develop and execute plans to meet established goals.
- Performs peer monitoring as directed by claims departmental leadership
- Provides ongoing feedback to help optimize quality performance.
- Collaborates with others and cross-departmentally to improve or streamline procedures.
- Remains current on industry trends and looks for new data sources.
- Develops new or improves current internal processes to improve quality
- This job description in no way states or implies that these are the only duties to be performed by this employee. The employee will be required to follow any other instructions and to perform any other duties requested by his/her supervisor.Minimum Qualifications:
- Associates degree in Medical Billing and Coding or Equivalent Experience
- Bachelor's degree preferred
- Minimum of 5 plus years of Claims Examiner Experience
- Knowledge of medical terminology is preferred.
- Working knowledge of computers and software including but not limited to Microsoft Office products
- Proficient mathematical, 10-key and typing skills
- Demonstrated organizational skills, problem-solving, analytical skills and detail oriented
- Demonstrated ability to remain neutral and maintain confidentiality
- Strong written and oral communication skills
- Demonstrated ability to work independently, prioritize workloads multi-task and manage priorities in order to meet deadlines
Work is indoors in an office environment with moderate noise. Intermittent physical effort involving lifting of up to 25 pounds, walking, and stooping, kneeling, crouching, or crawling is required. A typical workday involves sitting, frequent use of a keyboard, reaching with hands and arms, and talking and hearing, approximately 70% of the time. Approximately 30% or less of the time is spent standing. Normal vision abilities required, including close vision and ability to adjust focus.
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