Claims Examiner 2 (POPA)

Job Title

Claims Examiner 2

Department

Claims (Las Vegas)

Reports To

Brooke Reid

Job Duties

Investigates, analyzes, and determines extent of plan's liability concerning medical, dental, vision, pharmacy, and/or disability claims. Calculates benefit payments and approves payment of claims.

• Understanding of claims processing guidelines, benefit structure, system procedures, and miscellaneous guidelines.
• Calculate benefits and approve payment of claims.
• Refer questionable claims to team lead.
• Ability to work in Zenith's ETK system or comparable system by creating, updating, and resolving logs.
• Identify potential problems/trends in processes to be escalated for management
• review.
• Identify potential problems and possible solutions for process improvement.
• Create, update, and resolve logs in Zenith American's Encounter Tracking Systems or comparable system or its counterpart.
• Calculates overpayments and underpayments and approves payment of adjustments.
• Has strong understanding of claims processing guidelines, benefit structure, system procedures and miscellaneous guidelines.
• Adjunction of complicated claims and approves payment of claims.
• Must meet the department quality and production standards for this job, as provided on the work standards grid.
  
  

Job Requirements

Minimum Education & Experience

• High School diploma or GED
• Healthcare background/previous experience preferred
• Must have worked in Level 1 position for a minimum of 12 months.
• Must meet all level 2 qualifications, on average, during the previous 12 month period.
  
  

Mental/Visual Concentration or Manual Dexterity

• Requires normal concentration
• Easily learned, simple movements
  
  

Computer Operations

• Must be PC literate
• Working knowledge of HCFA, CPT, ICD-9, HCPCS, and other medical coding protocols
• Data entry and 10-key skills required
• Proficient in claims systems
  
  

Physical Work Environment

• Normal degree of physical effort in typical office environment with comfortable, constant temperatures and absence of objectionable elements
• May be subject to interruptions
• May be required to lift a maximum of 25 lbs
• Must be able to have flexible work schedule when workflow requires
• Meets established attendance and punctuality guidelines
  
  

Competencies

Customer Focus

• Understands customer needs, both internal and external, and looks for opportunities to provide the highest quality service
  
  

Quality Focus

• Maintains appropriate documentation
• Works with other employees/departments to ensure timely and quality service
• Must meet the departments quality and production standards for this job
  
  

Analysis

• Average analytical/problem solving skills
• Average research skills
• Mathematical proficiency required
  
  

Planning

• Solid organizational skills
• Ability to prioritize and multi-task
  
  

Communication

• Solid written, verbal, and presentation skills
• Listens actively
• Communicates effectively with participants, co-workers, and vendors
  
  

Interpersonal Relations

• Assists participants, co-workers, and vendors in a friendly, courteous, and professional manner
• Uses courtesy in communication and working with others
• Works with other employees/departments to ensure timely and quality service
• Patience and rapport with others required
  
  

Teamwork

• Works well in a team environment with minimal supervision
• Contributes to team tactics to meet defined goals
• Supports a work environment that is conducive to team productivity
• Accepts team decisions and works toward implementation
  
  

Positive Attitude

• Highly motivated
• Demonstrates flexibility and resilience when faced with multiple demands, shifting priorities, ambiguity, and rapid change
  
  

Integrity

• Approaches all business decisions and actions guided by sound personal and professional beliefs
• High level of credibility and confidentiality
• Earns trust by dealing honestly and following through on commitments
  
  

Salary

Grade V

Testing

Testing Requirements

• Pre-employment test for new hires
• Typing 10-key
• Claims test
  
  

Bid Instructions

Interested applicants should apply through our new ATS system

https://zenithamerican.applicantpro.com/internaljobs/ by COB Monday February 24, 2025. EMail

recruiting@zenith-american.com If you have any questions. The link can also be found on our intranet.

Zenith American Solutions

Real People. Real Solutions. National Reach. Local Expertise.

We are currently looking for a dedicated, energetic employee with the necessary skills, initiative, and personality, along with the desire to get the most out of their working life, to help us be our best every day.

Zenith American Solutions is the largest independent Third Party Administrator in the United States and currently operates over 44 offices nationwide. The original entity of Zenith American has been in business since 1944. Our company was formed as the result of a merger between Zenith Administrators and American Benefit Plan Administrators in 2011. By combining resources, best practices and scale, the new organization is even stronger and better than before.

We believe the best way to realize our better systems for better service philosophy is to hire the best employees. We're always looking for talented individuals who share our dedication to high-quality work, exceptional service and mutual respect. If you're interested in working in an environment where people - employees and clients - really matter, consider bringing your talents to Zenith American!

We realize the importance a comprehensive benefits program to our employees and their families. As part of our total compensation package, we offer an array of benefits including health, vision, and dental coverage, a retirement savings 401(k) plan with company match, paid time off (PTO), great opportunities for growth, and much, much more!