What are the responsibilities and job description for the Claims Examiner III position at Advanced Medical Manage?
Job Description
Job Description
Role Insights
This role of the Claims Examiner III is considered an essential position within the organization as well as the Claims Department. The Claims Examiner is responsible for collaborating with the Claims Team to meet productivity goals as well as ensure quality. This candidate should possess claims knowledge, prioritizing skills, and the ability to multi-task. This is not a routine position as it requires energy, enthusiasm, and the capability to be a valuable resource and team player to the entire Claims Team.
Primary Responsibilities
- Audit claims processing quality, develops, maintains and runs standard reports
- Assist the Claims Supervisor / Director in reviewing the quality auditing tracking / reporting (financial and procedural)
- Coordinating with various departments to resolve disputes or issues
- Maintain the Claims department workflow
- Review and process hospital claims and complicated claims to assist claims examiners I, and II
- Claims processing to ensure quality (in / out patient hospital claims, Medi-cal, Commercial, and Medi-care claims)
- Review auto adjudication of claims
- Review carve-outs in the Division of Financial Responsibility (DOFR)
- Review and process reports and work with management and claims unit
- Assist the Claims Manager in reviewing the quality auditing tracking / reporting
- Assist with training / supporting the claims team
- Recommend and assist in the development of process improvements
- Coordinating with various departments to resolve disputes or issues
- Able to process a claim and assist the team by answering questions and providing support
- Prepare for check runs
- Other duties may be assigned as needed to assist the AMM team
Required Skills and Abilities