Claims Examiner Ii

6 months ago

Gautam Budh Nagar, India ClearSource Full time

A Claims Examiner resolves and adjudicates medical and vision insurance claims. Reviews and adjudicates complex claims that include, but are not limited to, large dollar hospital, multiple surgery, and coordination of benefits. Assists with department training.
ESSENTIAL DUTIES AND RESPONSIBILITIES:

- Reviews electronic and paper insurance claim forms and related documents for completeness.
- Reviews claims information to determine the nature of a member’s illness or injury.
- Determines and understands the coverage provided under a member’s plan to determine if claims are payable according to EMI Health’s guidelines, policies and procedures.
- Exercises judgement within policy guidelines to makes claim payment decisions.
- Resolves exceptions and pends for medical, dental, and vision claims to a pay, pend, or deny status in a timely and accurate manner.
- Assists team members in support of achieving department and office goals.
- Understands and has accepted additional responsibility to handle three or more of the following:

- Large Dollar Claims
- Multiple Surgery
- Network Repricing Queues
- Medicare Claims including Demand Letters
- Fast Tracts
- Special Projects
- Javelina Testing
- Com-Com
- If cross-trained, may assist with dental claims.

**Requirements**:

- High school diploma or GED or two or more years of related experience and/or training; or equivalent combination of education and experience.
- Thorough knowledge of medical and vision terminology, coding, and health insurance benefit plans.
- Thorough knowledge of Medicare Secondary Payer and Coordination of Benefits rules, preferred.
- Basic communication skills, both written and verbal, with precision in grammar.
- Ability to read and comprehend instructions, correspondence, and reports.
- Ability to effectively present information in one-on-one and group situations to customers, clients and employees of the organization.
- Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions and decimals.
- Basic computer skills including Microsoft Office, Windows, and Outlook and web-based programs.
- Willing to work at the office.
- The employee must occasionally lift and/or move up to 10 pounds.

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