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Claims Examiner 2

3 months ago

Las Vegas, United States Zenith American Full time

JOB TITLE:

Claims Examiner 2

DEPARTMENT:

Claims (Las Vegas)

REPORTS TO:

Justine Barrientos

JOB DUTIES:

Investigates, analyzes, and determines extent of plan's liability concerning medical, dental, vision, pharmacy, and/or disability claims. Calculates benefit payments and approves payment of claims.

  • Understanding of claims processing guidelines, benefit structure, system procedures, and miscellaneous guidelines.
  • Calculate benefits and approve payment of claims.
  • Refer questionable claims to team lead.
  • Ability to work in Zenith's ETK system or comparable system by creating, updating, and resolving logs.
  • Identify potential problems/trends in processes to be escalated for management
  • review.
  • Identify potential problems and possible solutions for process improvement.
  • Create, update, and resolve logs in Zenith American's Encounter Tracking Systems or comparable system or its counterpart.
  • Calculates overpayments and underpayments and approves payment of adjustments.
  • Has strong understanding of claims processing guidelines, benefit structure, system procedures and miscellaneous guidelines.
  • Adjunction of complicated claims and approves payment of claims.
  • Must meet the department quality and production standards for this job, as provided on the work standards grid.

JOB REQUIREMENTS:

Minimum Education & Experience

  • High School diploma or GED
  • Healthcare background/previous experience preferred
  • Must have worked in Level 1 position for a minimum of 12 months.
  • Must meet all level 2 qualifications, on average, during the previous 12 month period.

Mental/Visual Concentration or Manual Dexterity

  • Requires normal concentration
  • Easily learned, simple movements

Computer Operations

  • Must be PC literate
  • Working knowledge of HCFA, CPT, ICD-9, HCPCS, and other medical coding protocols
  • Data entry and 10-key skills required
  • Proficient in claims systems

Physical Work Environment

  • Normal degree of physical effort in typical office environment with comfortable, constant temperatures and absence of objectionable elements
  • May be subject to interruptions
  • May be required to lift a maximum of 25 lbs
  • Must be able to have flexible work schedule when workflow requires
  • Meets established attendance and punctuality guidelines

COMPETENCIES:

Customer Focus

  • Understands customer needs, both internal and external, and looks for opportunities to provide the highest quality service

Quality Focus

  • Maintains appropriate documentation
  • Works with other employees/departments to ensure timely and quality service
  • Must meet the departments quality and production standards for this job

Analysis

  • Average analytical/problem solving skills
  • Average research skills
  • Mathematical proficiency required

Planning

  • Solid organizational skills
  • Ability to prioritize and multi-task

Communication

  • Solid written, verbal, and presentation skills
  • Listens actively
  • Communicates effectively with participants, co-workers, and vendors

Interpersonal Relations

  • Assists participants, co-workers, and vendors in a friendly, courteous, and professional manner
  • Uses courtesy in communication and working with others
  • Works with other employees/departments to ensure timely and quality service
  • Patience and rapport with others required

Teamwork

  • Works well in a team environment with minimal supervision
  • Contributes to team tactics to meet defined goals
  • Supports a work environment that is conducive to team productivity
  • Accepts team decisions and works toward implementation

Positive Attitude

  • Highly motivated
  • Demonstrates flexibility and resilience when faced with multiple demands, shifting priorities, ambiguity, and rapid change

Integrity

  • Approaches all business decisions and actions guided by sound personal and professional beliefs
  • High level of credibility and confidentiality
  • Earns trust by dealing honestly and following through on commitments

SALARY:

Grade V

TESTING:

Testing Requirements

  • Pre-employment test for new hires
  • Typing 10-key
  • Claims test

BID INSTRUCTIONS:

Interested applicants should apply through our new ATS system

by COB Tuesday, June 18, 2024. EMail

If you have any questions. The link can also be found on our intranet.



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