Medical Claims Examiner
4 days ago
Job Summary
The Claim Adjudicator is responsible for receiving, examining, verifying, and inputting submitted claims data, determining eligibility status, and reviewing and adjudicating claims within established timeframes. This position utilizes multiple systems to perform the day-to-day functions of processing medical, disability, vision, and dental claims, as well as provider and member-driven inquiries.
Key Responsibilities
- Screen claims for completeness of necessary information
- Verify participant/dependent eligibility
- Interpret plan benefits from the Summary Plan Description (SPD)/Plan Documents
- Code basic information and select codes to determine payment liability amount
- Evaluate diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered
- Determine the need for additional information or documentation from participants, employers, providers, and other insurance carriers
- Adjudicate claims according to established productivity and quality goals
- Request overpayment refunds, maintain corresponding files, and perform follow-up actions
- Handle verbal and written inquiries received from internal and external customers
- Achieve individual established goals to meet or exceed departmental metrics
- 2-3 years of related experience in a traditional medical claim adjudication environment (not a physician's office)
- Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
- Experience with eligibility verification, medical coding, coordination of benefits, and subrogation
- Experience with medical terminology, International Classification of Diseases (ICD)10, and Current Procedures Terminology (CPT) codes
Salary is $22.62 an hour. Actual base salary may vary based upon, but not limited to, relevant experience, qualifications, expertise, certifications, licenses, education, or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location. We offer a comprehensive benefits package, including medical, dental, vision, paid time-off, paid holidays, 401(k), pension, short- and long-term disability, life, AD&D, flexible spending accounts, commuter transit, tuition assistance, and employee assistance program.
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