CLAIMS EXAMINER

Summary: The Claims Examiner I is responsible for ensuring claims are coded and processed correctly and for meeting production requirements. Processes claims by performing the following duties.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Compares data on claim with internal policy and other company records to ascertain completeness and validity of claim.
• Comprehensive understanding of employee benefits for medical, dental and vision plans.
• Adjudicates medical claims, applies coordination of benefits as outlined in plan guidelines and works with providers to gather the necessary documents to make final payment determination on claims
• Ensures all claims are coded properly.
• Examines Summary Plan Document, claim adjustors' reports or similar claims/precedents to determine extent of coverage and liability.
• Maintains high quality standards to avoid paying claim incorrectly.
• Maintains productivity standards set by Management.
• Refers most questionable claims for investigation to claim examiner II for review and processing.
• Research and resolve paid and denied claims escalations from internal sources and/or TIPS ticketing system when assigned.
• Works from the claims queue manager to process & releases claims for adjudication and payment within 3-5 days of receipt.
• Performs other duties and responsibilities as assigned by Management.

Supervisory Responsibilities: This job has no supervisory responsibilities.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this

job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required to sit for extended periods in front of a computer. The employee is frequently required to reach with hands and arms and talk or hear. The employee is occasionally required to stand; walk and use hands to finger, handle, or feel. The employee may frequently lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus. This position requires the employee to work in the office.

Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

Knowledge, Skills, & Abilities:

• Excellent written and verbal communication skills.
• Strong analytical skills and problem-solving skills.
• Must be dependable and maintain excellent attendance and punctuality
• Must be able to perform data entry operations quickly and accurately.
• Ability to grow with changing demands of the position and the company.
• Strong computer skills, including Word, Excel, and Outlook.
• Successful candidates must have experience processing medical claims for an insurance company or third party administrator
• Must be highly proficient in ICD-10, CPT, and HCPCS codes.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience: Associate's degree (A. A.) or equivalent from two-year college or technical school; Must have 3-5 years employee benefits industry experience or equivalent combination of education and experience.

Language Skills: Ability to read, speak, and write effectively in English. Ability to interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports, meeting notes, project documentation, and correspondence. Ability to speak effectively before customers or employees of organization. Ability to effectively address or resolve customer service issues within guidelines of the position.

Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized or non-standardized situations.

Certificates, Licenses, Registrations: Valid, class C license in state working with no adverse driving record.