Claims Examiner

Summary:

Accurate review, input and adjudication of provider specialty claims, including UB04s, in accordance with outside regulations, internal production standards and the contractual obligations. Knowledge of medical terminology necessary. Strong knowledge of Commercial, Medicare and Medi-Cal codes. Basic PC knowledge with ability to research, review.

Duties and Responsibilities:

1. Accurately review all incoming Provider claims to verify necessary information is available.

2. Meets production standards of 100-150 Hospital claims per day and 200-250 IPA claims as established by claims management

3. Assists in other IPA’s when needed

4. Accurately enter claims data information into the computerized claims adjudication system.

5. Maintain all required documentation of claims processed and claims on hand.

6. Adjudicate claims in accordance with departmental policies and procedures and other rules applicable to specialty claims.

7. Maintain production standards established by claims management.

8. Coordinate resolution of claims issues with other Departments or Payers.

9. Assist Providers, Members and other Departments in claims research.

10. Provide backup for other examiners within the Department.

11. Assist in training of new claims personnel.

12. Promote a spirit of cooperation and understanding among all personnel.

13. Attend organizational meetings as required

14. Adhere to organizational policies and procedures.

15. Process Customer Care Inquires

16. Performs other tasks as assigned by supervisor/manager

Minimum Job Requirements:

High school graduate. One-year experience as a Claims Examiner on an automated claims adjudication system. Strong organizational and mathematical skills. Ability to generate claims status reports and/or check runs.

Knowledge, Skills and Abilities Required:

· Experience in a managed care environment preferred.

· ICD-9 and ICD-10 and CPT-4 coding knowledge preferred.

· Must be detail oriented and have the ability to work independently