What are the responsibilities and job description for the Medical Claims Examiner position at TEEMA - Litchfield Park?
Job Description
Job Description
Job Title : Contract Claims Examiner
Job Overview :
We are seeking an experienced Medical Claims Examiner to join our team on a contract basis. The ideal candidate will be responsible for reviewing, analyzing, researching, and resolving complex medical claims in accordance with claims processing guidelines and federal regulations. This role involves collaborating with various operational departments to ensure validation and quality assurance of claims processing.
Key Responsibilities :
Process complex medical claims submitted on CMS-1500 and CMS-1450 / UB-04 claim forms from healthcare providers, including facilities, physicians, Home Health, Durable Medical Equipment (DME) providers, and laboratories.
Review and analyze medical claims to ensure compliance with regulatory requirements, organizational policies, and claims processing guidelines.
Collaborate with departments such as Business Configuration, Network Management, Provider Data, Complaints, Appeals, and Grievances to resolve discrepancies and ensure accurate claims processing.
Identify and address potential claim issues, ensuring timely and efficient resolution in accordance with established guidelines.
Maintain a thorough understanding of federal regulations and compliance requirements, including Medicare, Medicare Advantage, Health Exchange, and TRICARE.
Perform quality assurance checks to validate claims accuracy and completeness before final adjudication.
Communicate effectively with internal teams and external stakeholders to facilitate claim resolutions and process improvements.
Utilize claims processing systems and software efficiently to track and manage claims workflow.
Qualifications :
Education : Associate's degree or equivalent job-related experience required.
Experience :
Minimum of 3 years’ experience in processing medical claims within the healthcare industry.
Strong knowledge and experience with managed care, Medicare, Medicare Advantage, Health Exchange, and TRICARE are highly desirable.
Familiarity with medical billing codes, claims processing guidelines, and healthcare regulatory compliance.
Proficiency in handling complex claims from various provider types, including facilities, physicians, and ancillary service providers.
Strong analytical skills with attention to detail and the ability to identify and resolve claim discrepancies.
Excellent organizational and communication skills, with the ability to work independently and collaboratively across departments.
Work Schedule :
Monday to Friday, 8-hour shifts.
Remote and / or hybrid opportunities may be available based on business needs.
