The Claims Examiner I adjudicates health services claims of basic complexity levels. Researches, analyzes, and calculates claims benefits and payments in accordance with the current MDX Hawai‘i rules, policies, procedures and contracts.
- Basic CMS1500 claims: Capitated and Fee-For-Service physician services i.e. office visits, anesthesia and unknown member and provider claims.
- Basic CMS1500 claims: Laboratory and Radiology
- Basic Outpatient UB04 claims: Clinic Visits, Free Standing ASC, Radiology and Laboratory
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Regularly and dependably reports to work as scheduled. Follows all Company policies and procedures, including but not limited to personnel policies, safety policies and operational policies as communicated by management. Follows all Department policies and procedures, including, but not limited to procedural guidelines/workflows, attendance requirements and performance requirements as communicated by management. In accordance with State and/or Federal confidentiality/privacy laws, maintains confidentiality of all company, provider, member and client information as specified by Company confidentiality policies and procedures. Represents the Company in a professional manner at all times when dealing with both internal and external customers. Adjudicates assigned claims based on applicable conditions, including but not limited to, department policies, procedures and workflows, provider contracts and health plan benefits. Assist with researching claims issues referred to the Claim Department. Maintains all claims records.
EDUCATION AND/OR EXPERIENCE: High School Graduate or equivalent One (1) year experience processing medical claims