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
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