Claims Examiner

Job Summary

• This position is responsible for following written criteria, policies and procedures in reviewing and processing claims received from Out of Group providers to determine if such claims are appropriate for payment.
• The position also considers eligibility, benefits, authorizations, coding, compliance, contracted payment terms and health plan contracts to decide the disposition of a claim.
• The contracts can change annually and the examiner must be able to apply the correct terms to the claims.
• If the claim is not appropriate for payment, the examiner is responsible for making sure that the denial is done correctly in the system so that the letter will print correctly.
• There are internal, external and governmental timeliness standards that consistently need to be met.
• This position has the freedom to pay or deny medical services by using the policy guidelines of the department and to process sensitive and confidential information.
• If the claim & information received does not meet our department policy guidelines, this position must refer the claim and documentation to UM department as appropriate.
• This position could have contact with Eligibility, Member Services, UM, providers, the Health Plans and any applicable staff.
• Additionally, there are production and quality standards that must be maintained.
• This position will have responsibility for working independently on assigned tasks and activities, based on established policies and procedures

Minimum Qualifications :