Claims Examiner - M

Claims Examiner, Tucson, AZ

The Claims Examiner needs experience with ICD-10, Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), In-Patient Billing, Rejections, Accounts Receivable (A/R), Account Reconciliation, and Prior Authorizations. Candidates also need experience with Medicare/Medicaid Billing, Medicare/Medicaid Claims, In-Patient Billing, and Rejections.

Under general supervision from the Director of Operations, the responsibility of Claims Examiner consists of processing claim data and adjudicating medical and inpatient claims received from all provider types and lines of business. Review and resolve rejected and/or denied claims. Conduct research and analysis of claims; facilitate resolution of specific claims issues. Monitor copays, deductibles, insurance verification, and authorizations. Analyze incoming and outgoing revenue sources and measure different financial cycles on behalf of customers. Maximize reimbursement and develop effective policies for billing and claim processing. This position is 100% Onsite and NOT open for Remote.

Claims Examiner Responsibilities:

- Submit claims and encounters in a timely manner.

- Review and resolve rejected, pended, and/or denied claims within expected timeframes.

- Coordinate claim adjustments with the customer.

- Identify revenue cycle issues and implement solutions to improve systems and processes.

- Respond to calls on claims issues and provide information and resolution in a timely manner.

- Provide education and technical support to Claims Examiners and customers regarding claims related issues through on-line training and in person training.

- Produce scheduled reports for in-house and customers.

- Prepare written inter-departmental and external correspondence.

- Develop and publish formal written guidance for customers to process claims.

- Analyze encounter-processing data using statistical methodologies.

- Update and maintain electronic billing manual and distribute updates as directed.

- Compare business operations and coordinate technical analysis support for upcoming collection of accounts.

Claims Examiner Qualifications:

- The Claims Examiner needs experience with ICD-10, Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), In-Patient Billing, Rejections, Accounts Receivable (A/R), Account Reconciliation, and Prior Authorizations.

- Candidates also need experience with Medicare/Medicaid Billing, Medicare/Medicaid Claims, In-Patient Billing, and Rejections.

- High School diploma or GED plus 5 years of full-time data entry experience in claims processing, accounting, analysis and adjudication of Medical and/or Behavioral environment.

- Experience with ICD-10, CPT, Healthcare Common Procedure Coding System (HCPCS), and Inpatient coding and billing and knowledge of HIPAA regulations.

- Knowledge of Microsoft Excel and 10-key by touch is also required.

- Knowledge of and experience working with Electronic Health Records system(s).

- Ability to translate customer needs to technical and/or business process solutions.

- Ability to effectively work with internal teams across numerous functions and levels.

- Ability to quickly learn complex business processes and understand the underlying transactional systems.

- Strong customer service skills and abilities.

- Exceptional communication skills, including strong customer-facing presentation and facilitation skills.

- Ability to work on multiple projects.

- Strong attention to detail and follow-through skills.

- Experience working in a team-oriented, collaborative environment.

- Strong analytical and problem-solving abilities.

Benefits include medical insurance, retirement plan, PTO, etc.

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