Position Summary

The Collections and Claims Examiner II is responsible for processing submitted electronic claims to ensure proper filing procedures and that processing guidelines and rules have been followed. The Collections and Claims Examiner II also validates claim or referral submissions to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements.

Duties and Responsibilities

• Conduct analysis around various claims payment processes to ensure accuracy of system configuration and provider payments.
• Investigate and resolve problem claims, while focusing on improving errors and problems to prevent future occurrences.
• Perform and execute various claims process testing requests to ensure desired results are met to support accurate claims payments.
• Analyze and adjudicate complex claims that cannot be auto adjudicated.
• Adjudicate claims by, including but not limited to, applying medical necessity guidelines, determining coverage and completing eligibility verification, identifying discrepancies and applying all cost containment measures.
• Process medical claims by approving or denying documentation, calculating benefits due initiating a payment or denial letter.
• Follow any center for Medicare and Medicaid (CMS) changes affecting claims processing.
• Perform pre-payment audit.
• Follow company policies, procedures and guidelines to ensure legal compliance.
• Update claims knowledge by participating in educational opportunities, whether system oriented or medical coding/terminology/interpretation.
• Update and maintain departmental and specialty network standards of operating procedure (SOP).
• Complies with performance standards as set forth by the department head.
• Perform posting charges and completion of claims to payers in a timely fashion.
• Assume the responsibility of receiving and sorting incoming payments with attention to credibility.
• Following up on unpaid claims within standard billing cycle timeframe - Handle collections on unpaid accounts.
• Accurately Post all insurance payments by line item.
• Calling Insurance Companies regarding any discrepancy in payments if necessary - Timely follow up on insurance claim denials, exceptions or exclusions.
• Reading and interpreting insurance explanation of benefits.
• Obtaining referrals, medical records and authorizations as required for procedures -Make necessary arrangements for medical records requests, completion of additional information requests, etc. as requested by insurance companies.
• Respond to inquiries from insurance companies and providers.
• Investigate, researching and appealing denied claims
• Regularly meet with VP of Operations - to discuss and resolve reimbursement issues or billing obstacles.
• Updating monthly payments spreadsheets, running payment reports and current collections reports.
• Monitor and follow up with the Health Plans regarding the aging’s.

Knowledge

• 6 of Claims Adjustment experience/ previous claims processing experience.
• Knowledge in Podiatry, Orthopedic, Dermatology and/or Pain Management specialties preferred.
• Knowledge of HIPAA policies and Compliance.
• Medical Terminology including ICD (10) and CPT Knowledge.
• Associates degree preferred

Skills

• Proficient in Microsoft Office programs.
• Previous experience with systems processing.
• Research skills