Health Claims Examiner

Role Overview

• Accurate and timely processing of medical, dental, vision and prescription drug claims
• Provide courteous and prompt responses to customer inquiries
• Communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public
• Verify the accuracy and receipt of all required documentation for each claim submitted
• Collaborate with providers, plan participants, other claims payers, or any other party necessary to obtain information necessary to accurately process a claim
• Analyze information necessary for processing
• Assure that the system processes the claim correctly and determines payment according to the plan as written
• Word-processes correspondence to plan participants and providers in reference to pre-determinations and in response to basic benefit questions
• Answers telephone calls from plan participants, group contacts, and customer service representatives pertaining to benefits and claims inquiries
• Resolve problematic claims with the assistance of the Team Leader, Claims Manager and/or the Director of Claims
• Assign critically ill patients to large case management
• Assist the case manager with direct negotiation and the efficient use of benefits
• Assist other examiners as needed due to workload requirements
• Aids the Team Leader and/or the Claims Manager in the resolution of claim appeals and disputes by providing documentation for review
• Research, calculate and request refunds when necessary
• Contributes to the daily workflow with regular and punctual attendance
• Thoroughly research and complete renewal reports in a timely manner in consultation with the Marketing Department
• Process eligible claims on groups before the end of their stoploss contract renewal period
• Assist the Legal Department with subrogation claims as necessary
• Attend various group meetings as required
• Assist with audits as needed
• Assist with plan benefit set-up and changes as needed

Requirements

• 1+ year of LUMINX Processing experience is required
• High school graduation or GED required
• Excellent oral and written communication skills required
• PC skills, including Windows and Word
• Ability to learn all functions of the claims processing software as is necessary for claims processing and adjudication
• Typing ability of 45 wpm net
• Excellent listening skills
• Basic mathematical skills
• High level of interpersonal skills to work effectively with others
• Ability to organize and recall large amounts of detailed information
• Ability to read, analyze and interpret benefit summary plan descriptions, insurance documents, plan benefits, and regulations and make appropriate applications to specific situations
• Ability to meet productivity standards with 99% financial accuracy and 95% procedural accuracy
• Thorough knowledge of claims processing procedures and requirements
• Ability to project a professional image and positive attitude in any work environment
• Ability to comply with privacy and confidentiality standards
• Ability to be flexible, work under pressure and meet deadlines
• Ability to analyze and solve problems with professionalism and patience, and to exercise good judgment when making decisions
• Ability to operate typical office equipment
• Working knowledge of general office procedures

Benefits

• Internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload