Medical Claims Examiner

The Claims Examiner I is responsible for ensuring claims are coded and processed correctly and for meeting production requirements. Responsibilities: Compares data on claim with internal policy and other company records to ascertain completeness and validity of claim. Comprehensive understanding of employee benefits for medical, dental and vision plans. Ensures all claims are coded properly. Examines Summary Plan Document, claim adjustors' reports or similar claims/precedents to determine extent of coverage and liability. Maintains high quality standards to avoid paying claim incorrectly. Maintains productivity standards set by Management. Refers most questionable claims for investigation to claim examiner II for review and processing. Research and resolve paid and denied claims escalations from internal sources and/or TIPS ticketing system when assigned. Works from the claims queue manager to process & releases claims for adjudication and payment within 3-5 days of receipt. Performs other duties and responsibilities as assigned by Management. Qualifications: Excellent written and verbal communication skills. Strong analytical skills and problem-solving skills. Must be dependable and maintain excellent attendance and punctuality. Must be able to perform data entry operations quickly and accurately. Ability to grow with changing demands of the position and the company. Strong computer skills, including Word, Excel, and Outlook. Must be highly proficient in

ICD-10, CPT, and HCPCS codes. Education: Associate's degree (A. A.) or equivalent from two-year college or technical school; Must

have 3-5 years employee benefits industry experience

or equivalent combination of education and experience Seniority level

Mid-Senior level Employment type

Contract Job function

Information Technology Industries

Information Services

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