Claims Examiner I

6 months ago

Gautam Budh Nagar, India ClearSource Full time

Resolves and adjudicates medical and vision insurance claims.

ESSENTIAL DUTIES AND RESPONSIBILITIES
- Resolves exceptions and pends for medical and vision claims to a pay, pend, or deny status in a timely and accurate manner.
- 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 claim judgement within policy guidelines to makes claim payment decisions to pay, request additional information or deny a claim.
- Assists team members in support of achieving department and office goals.
- Attends department meetings and training sessions.

**Requirements**:

- High school diploma or GED or two or more years of related experience and/or training; or equivalent combination of education and experience.
- General knowledge of medical and vision terminology, coding, and health insurance benefit plans.
- General 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.
- Must occasionally lift and/or move up to 10 pounds.

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