Position Overview The Claims Examiner I is responsible for the data entry and system adjudication of provider claims. The incumbent authorizes final disposition of claims within prescribed guidelines in an accurate and timely manner. Scope of Role & Responsibilities: Process claims involving medical and/or surgical services; screens for complete member/provider information Apply administrative policies when necessary, utilizing the claims processing manuals Authorizes the generation of letters/questionnaires to providers to obtain additional information Reviews descriptions of services on claims to determine validity of charges of the presence of errors Evaluates and examines claims pended by the system due to contractual and/or payment discrepancies Maintains production and quality goals established for the department Performs other related duties, i.e., maintaining individual production counts, updating manuals and reference materials, attending all refresher training seminars Required Education, Training & Professional Experience Associate's Degree required; and Minimum 2 years' experience in the healthcare insurance industry with knowledge of integrated claims processing; or A satisfactory equivalent combination of education, training, and experience Proficiency with data entry skills Through knowledge of medical terminology, CPT, ICD-p, and Revenue Codes Professional Competencies Integrity and Trust Customer Focus Functional/Technical skills Written/Oral Communication
Not specified in the original listing.
Not specified in the original listing.
