Medical Insurance Claims Examiner

4 weeks ago


Sunrise Manor, Nevada, United States Community Care Plan Full time
Job Summary

Community Care Plan is seeking a highly skilled Medical Insurance Claims Examiner to join our team. As a Medical Insurance 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: Thorough knowledge of coding structures (CPT, HCPCS, Revenue codes, ICD10, DRG, etc.).
  • Third-Party Coordination: Identify third-party or coordination of benefits issues and notify designated claims department Coordination of Benefits (COB) personnel for timely review and resolution.
  • Benefits Knowledge: 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.).
  • Claim 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 Processing: 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.
Requirements
  • 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.


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