Claims Examiner 2 (POPA)

JOB TITLE:

Claims Examiner 2

DEPARTMENT:

Claims (Las Vegas)

REPORTS TO:

Justine Barrientos

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 Tuesday, June 18, 2024. EMail

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