Claims Examiner

7 days ago

Navi Mumbai, Maharashtra, India DECTREE INFOTECH PVT LTD Full time

NAME Open Position
DEPTARTMENT:
Administration

TITLE Claims Examiner
STATUS:
Full-time

REPORTS TO:
Manager of TPA Operations
CLASSIFICATION Non-Exempt

JOB SUMMARY/ORGANIZATIONAL IMPACT:

Serves self-insured clients by determining insurance coverage; examining and resolving medical claims; documenting actions; maintaining quality customer services; ensuring legal compliance.


RESPONSIBILITIES/ ESSENTIAL FUNCTIONS:

  • Ability to analyze, review and adjudicate provider claims
  • Resolves medical claims by approving or denying documentation; calculates benefit amounts due; initiates payment and/or composes denial letter.
  • Ensures the legal compliance of client policies, procedures, and guidelines, as well as legal compliance with state and federal regulations during the claim process.
  • Review claims to determine if costs were reasonable and/ or medically necessary.
  • Report overpayments, underpayments and other irregularities to supervisor.
  • Communicate with reinsurance brokers to obtain information necessary for processing claims.
  • Be able to integrate knowledge as a skilled specialist to solve problems and find new efficient workflows.
  • Protects operations by keeping claims information confidential; must be HIPPAA compliant.
  • Recognize areas of weakness, provide suggestions, and update documentation for process improvement.
  • Perform general and administrative duties as assigned.
Page 1 of 3

REQUIRED QUALIFICATIONS:
Abilities**
Knowledge Oral Expression
. The ability to communicate information and ideas in speaking so others
-
Customer and Personal Service. will understand.

Knowledge of principles and processes for providing customer and personal services. Speech Clarity
. The ability to speak clearlyThis includes customer needs assessment, so others can understand you. meeting quality standards for services, and evaluation of customer satisfaction. Problem Sensitivity**- The ability to tell when something is wrong or is likely to go wrong. It
Clerical.

*Knowledge of administrative and does not involve solving the problem, only clerical procedures and systems such as recognizing there is a problem.

word processing, managing files and records, stenography and transcription,
-
Written Expression. The ability to designing forms, and other office procedures communicate information and ideas in writing and terminology. so others will understand.
Skills
-
Active Listening.

Giving full attention to
Experience:


what other people are saying, taking time to
Possess deep domain knowledge in understand the points being made, asking Healthcare and Insurance domain questions as appropriate, and not interrupting at inappropriate times.



  • Experience in processing claims for inpatient,
-
Speaking. Talking to others to convey outpatient facility and professional services information effectively.

  • 13 years of healthcare reimbursement
-
Service Orientation. Actively looking for experience such as provider contract ways to help people development, healthcare claims analysis, medical billing/coding, patient accounting,
-
Critical Thinking. Using logic and claims auditing, and/or revenue cycle reasoning to identify the strengths and improvement required. weaknesses of alternative solutions, conclusions or approaches to problems.

Must have demonstrated experience and knowledge of healthcare claims processing:

  • Social Perceptiveness*. Being aware of(Medicaid, Medicare, Commercial others' reactions and understanding whyInsurance), including ICD9CM codes, they react as they do.
HCPCS codes, CPT codes, DRGs, physician
-
Persuasion. Persuading others to change billing, etc. preferred. their minds or behavior.

Education Required:

  • In depth knowledge of coding principals including but not limited to NCCI Edits, CPT,
    Associates degree, technical college or some
HCPCS and ICD-9 codes and modifiers; college course work preferred and/or MSDRG, Revenue codes, and APCs.

Certifications:

  • In depth knowledge of UB04 and medical
(1500) claim formats and requirements.

  • Sound understanding or medical terminology and anatomy.
Page 2 of 3

AUTHORITY


This position does not have the authority; neither express nor implied, to legally bind the Company to any contract without written, documented consent of an Officer of the Company.


SPECIAL JOB DIMENSIONS:

This position requires sitting for long periods of time.

ATTENDANCE:

Employee must have the ability to comply with the company's attendance policy documented in the Employee Manual.

PHYSICAL REQUIREMENTS AND WORK ENVIRONMENT


While performing the duties of this job, the employee is regularly required to sit for long periods of time and must have the dexterity of hands and fingers to operate a computer keyboard, mouse, and other office equipment.

The employee must have visual acuity to read and draft reports, memos, letters, etc. Specific vision abilities re

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