Claims Examiner

About Company:

PayerFusion provides cost containment and medical claims processing achieves claim integrity and bill reductions

PayerFusion’s TPA services utilize the latest medical claim processing technology coupled with our unique healthcare cost containment methodologies to provide you with the sharpest advantage possible. Our rules-driven medical claim administration tools enable you to remain competitive and compliant in an environment of ever-increasing costs and regulations.

We take pride in being the solution for self-funded programs, international insurers, providers and anyone who requires unique and effective health plan and third-party administration services.

As it relates to International Services, at PayerFusion Holdings, LLC, we offer our services for self-funded programs, international insurers, providers and anyone who requires unique and effective health plan and third-party administration services.

PayerFusion approaches in healthcare industry in a manner that aims to “fuse” the gap between payers and providers by creating win-win situations in health benefits and claims administration – including medical claims pricing.

PayerFusion employs the latest technology to give the clients control of their medical claims administration and truly reduces the costs and loss ratios. Cost per claim and policy performance are not forgotten, our TPA services and cost containment process provides excellent reporting capabilities.

About the Position:

We are seeking a dedicated and detail-oriented Claims Examiner to join our team. In this role, you will be responsible for processing and examining claims, ensuring accuracy and compliance with company policies, and supporting our cost containment efforts. The ideal candidate will have a strong understanding of insurance policies, coding, and claims processing.

Key Responsibilities:

• Claims Processing & Examination: Process and examine all incoming claims following departmental procedures to ensure timely and accurate claim resolution.
• Policy Interpretation: Interpret and apply policy terms, including deductibles, coinsurance, copays, and policy maximums.
• Coding Knowledge: Utilize ICD-10 coding and understand how to process claims, read and interpret policies, apply CPT codes, hospital coding, UB-04 forms, and adhere to Correct Coding Initiative (CCI) principles.
• Network & Cost Containment: Research and verify the appropriate PPO network or direct contract for each claim, ensuring the greatest cost savings for clients while supporting PayerFusion’s cost containment efforts.
• Quality Assessment: Perform quality checks on claims to minimize errors and ensure accuracy. Identify claims exceeding pre-established criteria that should be audited by the Medical Team.
• Follow-Up & Deadlines: Ensure timely follow-up on pending network claims to meet established deadlines and maintain workflow efficiency.
• Provider Interaction: Manage provider statements and invoices by reaching out to providers for clarification and complete documentation.
• Client Commitment: Meet promised deadlines for claims processing and maintain high levels of client satisfaction.
• Additional Duties: Perform other office duties as assigned by the Claims Supervisor/Manager.

Qualifications:

• Education: High school diploma required; associate’s or bachelor’s degree in related field preferred.
• Experience: 2-3 years of experience in claims processing or insurance-related fields.
• Technical Skills: Knowledge of ICD-10, CPT codes, UB-04, and Correct Coding Initiative principles. Proficiency in claims management systems and Microsoft Office programs such as Microsoft Excel, Word, Outlook and Teams..
• Strong Attention to Detail: Excellent organizational and analytical skills, with a keen eye for identifying and resolving issues.
• Communication Skills: Effective communication abilities to work with internal teams and external providers.

Benefits

• Health, Dental, Vision, Hospitalization and Life Insurance benefits
• 401K benefits with match of up to 4%
• 12 Holidays Paid
• PTO