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Medical Claims Examiner

4 months ago

Folsom, United States System Soft Technologies Full time

This is an on-site position- Folsom CA


Summary:

The Claims Examiner I is responsible for ensuring claims are coded and processed correctly and for meeting production requirements. Processes claims by performing the following duties.


Essential Duties and Responsibilities include the following. Other duties may be

assigned.

  • Compares data on claim with internal policy and other company records to ascertain completeness and validity of claim.
  • Comprehensive understanding of employee benefits for medical, dental and vision plans.
  • Adjudicates medical claims, applies coordination of benefits as outlined in plan guidelines and works with providers to gather the necessary documents to make final payment determination on claims
  • Ensures all claims are coded properly.
  • Examines Summary Plan Document, claim adjustors' reports or similar claims/precedents to determine extent of coverage and liability.
  • Maintains high quality standards to avoid paying claim incorrectly.
  • Maintains productivity standards set by Management.
  • Refers most questionable claims for investigation to claim examiner II for review and processing.
  • Research and resolve paid and denied claims escalations from internal sources
  • and/or TIPS ticketing system when assigned.
  • Works from the claims queue manager to process & releases claims for adjudication and payment within 3-5 days of receipt.
  • Performs other duties and responsibilities as assigned by Management.


Knowledge, Skills, & Abilities:

  • Excellent written and verbal communication skills.
  • Strong analytical skills and problem-solving skills.
  • Must be dependable and maintain excellent attendance and punctuality
  • Must be able to perform data entry operations quickly and accurately.
  • Ability to grow with changing demands of the position and the company.
  • Strong computer skills, including Word, Excel, and Outlook.
  • Successful candidates must have experience processing medical claims for an insurance company or third party administrator
  • Must be highly proficient in ICD-10, CPT, and HCPCS codes.


Education and/or Experience:

Associate's degree (A. A.) or equivalent from two-year college or technical school; Must have 3-5 years employee benefits industry experience or equivalent combination of education and experience.


Benefits:

  • Medical, Dental, Vision- eligibility is 30 days from start date. We pay for the employee’s benefits, if they have dependents, they will have to pay for dependents.
  • 401k-BRMS matches 100% up to 3%, eligibility is 30 days from start date
  • 10 paid Holidays
  • PTO: they accrue 120 hours the first year
  • Sick time: 40 hours after they have worked 90 days