Claims Examiner

**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 over-payments, 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.

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**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.
- 1-3 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 ICD-9-CM 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.

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**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