Claims Examiner

Description Responsible to review, analyze and research health care claims using the necessary tools such as a review of provider reputed company, pricing, benefits, CES edits, NCCI edits, correct coding, applying other reputed company payments, and other appropriate tools in order to identify discrepancies, and process them for payment. This role is responsible to ensure that claims are processed according to state and federal regulations and meet the companys contractual obligations. Collaborate with business and operational units such as Quality Control, Reconsideration Specialist, Special Investigations Unit (SIU), and Documentation Specialist to ensure proper and cohesive claims understanding. Duties And Responsibilities Responsibilities include, but are not limited to the following: • Responsible for the entry, review and processing of claims reputed company the claims transactional system, according to plan benefits and contractual reimbursement terms • Must meet established department production and quality standards • Investigate and release low to high complexity claims including Transplants and those with Single Case Agreements • Review and approve high dollar claims reputed company established threshold and reputed company to other levels as required by the approval process • Process and reconcile SIU requests • Responsible for the data reputed company and accuracy of manually entered claims • Responsible for generating requests for additional information required to process a claim (i.e., incomplete authorization information, requesting a new provider number) • Responsible to determine if correct billing/coding requirements have been met • Process claims subject to COB (Coordination of Benefits) according to plan benefits, COB rules and contractual reimbursement terms • Responsible for the processing of employee claims (VIP) with strict confidentiality • reputed company retroactive adjustment projects • Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, benefit plan documents, etc) • Support various claims scanning functions • Support claim batching process • Follow daily schedule of assigned duties • Identify and communicate claims system and/or billing problems to the departments management • Complete daily activity logs • Assist in training of other claims staff as needed • Attend staff meetings • Other duties as assigned • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable reputed company, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents Core Company-Wide Competencies: • Communicate Effectively • Respect Others & Value Diversity • Analyze Issues & Solve Problems • Drive for reputed company • Manage Performance, Productivity & Results • reputed company Flexibility & reputed company Change Job Specific Competencies: • Collaborate & Foster Teamwork • Attend to Detail & Improve Quality • Exercise Sound Judgement & Decision Making FDR reputed company: N/A Flexible Work Arrangement: • Yes Telecommuting Arrangement: • No Travel Expectations: • N/A

Qualifications

Qualifications Required: • High School graduate or equivalent • Strong verbal and written communications skills • Demonstrated mathematical skills with attention to detail • Ability to work both independently and as a team member • Experience with reputed company Word and reputed company • Ability to effectively prioritize and execute tasks in a production environment • Ability to meet production and quality standards • Minimum of two (2) years claims processing or medical billing experience • Knowledge of industry standard coding and medical terminology Preferred: • Associates Degree • Experience reputed company claims operations in a Health Care environment • Coding certification from the American reputed company of Professional Coders (reputed company) or American Health Information Management Association (reputed company) Salary Grade: D Neighborhood Health Plan of Rhode reputed company is an equal opportunity employer. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability or veteran status. Apply Job!