Day-to-day processing of claims for accounts:
Responsible for processing of claims (medical, dental, vision, and mental health claims)
Claims processing and adjudication.
Claims research where applicable.
Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic).
Incumbents are expected to meet and/or exceed qualitative and quantitative production standards.
Investigation and overpayment administration:
Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers.
Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records.
Utilize systems to track complaints and resolutions.
Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading.

2+ years related work experience.
Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry.
High school diploma or GED
Knowledge of CPT and ICD-10 coding required.
Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required.
Must possess proven judgment, decision-making skills and the ability to analyze.
Ability to learn quickly and multitask.
Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers.
Concise written and verbal communication skills required, including the ability to handle conflict.
Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding.
Review of multiple surgical procedures and establishment of reasonable and customary fees.

Claims Examiner I

Key skills