Medical Claims Examiner
4 days ago
We are seeking a highly skilled Medical Claims Examiner to join our team at Community Care Plan. As a Medical Claims Examiner, you will be responsible for accurately and efficiently processing health insurance claims in accordance with established production and quality department standards.
Key Responsibilities- Claims Adjudication: Adjudicate and enter claims for all lines of business according to benefit plan designs and regulatory standards.
- Claims Review: Review claims based on coverage benefits, coding guidelines, medical review determination, billing discrepancies, and cost containment measures.
- Coding Knowledge: Possess thorough knowledge of coding structures (CPT, HCPCS, Revenue codes, ICD10, DRG, etc.).
- Coordination of Benefits: Identify third-party or coordination of benefits issues and notify designated claims department Coordination of Benefits (COB) personnel for timely review and resolution.
- Benefits and Calculations: Knowledgeable of COB and familiarity with benefits and benefit calculations.
- Claims Pricing: Ability to understand and manually calculate all types of claims pricing (Medicaid, Medicare, and UCR - Usual, Customary and Reasonable, etc.).
- Claims Research: Research all complex claims, disputes, and appeals thoroughly to make accurate payment decisions in a timely manner with input from the Claims Analysts for quality assurance.
- Claim Corrections: Process claim corrections and COB updates via interdepartmental customer relationship management process.
- Production Reports: Generate and review production reports daily for quality and training purposes.
- Department Goals: Maintain quantity/quality department goals regarding the number of claims entered and accuracy percentages.
- Training and Development: Complete side-by-side and peer training as necessary for educational opportunities.
- Education: High School or General Education Diploma (GED) and two to four years related experience and/or training; or equivalent combination of education and experience.
- Certification: Medical Coding Certification, CPC or equivalent preferred.
- Software Skills: Knowledge of word processing software, spreadsheet software, internet software, and Epic software.
As a Medical Claims Examiner at Community Care Plan, you will work in a hybrid environment, with the ability to work from home three days a week and report to the office two days a week. The company reserves the right to change the work schedules based on company needs. Potential start times are between 6:30 am and 9 am.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
We are an equal opportunity employer who recruits, employs, trains, compensates, and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.
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