Summary

The claims examiner is responsible for the adjudication of claims, in accordance with outside regulations and the contractual obligations of the Health Plans and/or the IPAs. Researches, reviews and contacts provider services for problem claims and issues, as needed. Suggests process improvements to management and is a resource of information to all staff.

Duties and Responsibilities

· Accurately review all incoming Provider claims to verify necessary information is available.

· Adjudicate claims in accordance with departmental policies and procedures and other rules applicable to specialty claims.

· Coordinate resolution of claims issues with other Departments.

· Assist Providers, Members and other Departments in claims research.

· Provide backup for other examiners within the Department.

· Assist in training of new claims personnel.

· Promote a spirit of cooperation and understanding among all personnel.

· Attend organizational meetings as required

· Adhere to organizational policies and procedures.

· Performs other tasks as assigned by supervisor/manager

· Adhere to MedPOINT Management’s core value: Accountability, Community, Celebration, Integrity, Innovation & Collaboration

Minimum Job Requirements

High school graduate. One-year experience as a Claims Examiner on an automated claims adjudication system. Strong organizational and mathematical skills. Ability to generate claims status reports and/or check runs.

Skill and Abilities

· Experience in a managed care environment preferred.

· ICD-10 and CPT-4 coding knowledge preferred.

· Must be detail oriented and have the ability to work independently