Claims Examiner
Community Care Plan Careers
 Fort Lauderdale, FL

Requisition Number: CLAIM01296

POSITION SUMMARY:

Responsible for the accurate and timely adjudication of health insurance claims in accordance with established production and quality department standards by performing the following duties:

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  1. Adjudicates and enters claims for all lines of business according to benefit plan designs and regulatory standards.
  2. Reviews claims based on coverage benefits, coding guidelines, medical review determination, billing discrepancies and cost containment measures.
  3. Thorough knowledge of coding structures (CPT, HCPCS, Revenue codes, ICD10, DRG etc.)
  4. Identifies third party or coordination of benefits issues and notifies designated claims department Coordination of Benefits (COB) personnel for timely review and resolution.
  5. Knowledgeable of COB and familiarity with benefits and benefit calculations
  6. Ability to understand and manually calculate all types of claims pricing (Medicaid, Medicare, and UCR - Usual, Customary and Reasonable, etc.)
  7. Identifies inappropriate or questionable claims and refers to Claims Analysts for review.
  8. Researches 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.
  9. Processes claim corrections and COB updates via interdepartmental customer relationship management process.
  10. Generates and reviews production reports daily for quality and training purposes.
  11. Maintain quantity/quality department goals regarding the number of claims entered and accuracy percentages.
  12. Complete side by side and peer training as necessary for educational opportunities.
  13. Assists with projects and clerical support as needed.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

QUALIFICATIONS:

  • High School or General Education Diploma (GED) and two to four years related experience and/or training; or equivalent combination of education and experience.
  • Medical Coding Certification, CPC or equivalent preferred.
  • Knowledge of word processing software, spreadsheet software, internet software, and Epic software.

SKILLS AND ABILITIES:

  • Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
  • Ability to write routine reports and correspondence.
  • Verbal and written communication skills.
  • Ability to perform arithmetic calculations.
  • Ability to work independently.
  • Ability to meet deadlines.
  • Ability to maintain a good rapport and cooperative working relationship with the team.
  • Ability to speak effectively before groups of customers or employees of organization.
  • Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.
  • Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.
  • Ability to deal with problems involving several concrete variables in standardized situations.
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