Claims Examiner

Job Description

REQUIREMENTS

• At least 1-2 years of experience working closely with healthcare claims or in a claims processing/adjudication environment.
• Understanding of health claims processing/adjudication
• Ability to perform basic to intermediate mathematical computation routines
• Medical terminology strongly preferred
• Understanding of ICD-9 & ICD-10
• Basic MS office computer skills
• Ability to work independently or within a team
• Time management skills
• Written and verbal communication skills
• Attention to detail
• Must be able to demonstrate sound decision-making skills

RESPONSIBILITIES

• Review and adjudicate medical claims, ensuring accurate coding, data entry, and application of appropriate reimbursement methodologies.
• Verify patient eligibility, provider credentialing, and coverage details to facilitate accurate claims processing.
• Communicate with internal resources, and internal stakeholders to resolve claim discrepancies, request additional information, or clarify issues.
• Participate in ongoing training and professional development activities.
• Maintain accurate and detailed records of claims processing activities.
• Review claim forms and supporting documents
• Determine eligibility, verify data accuracy
• Request additional information when needed
• Process claims end-to-end
• Identify and escalate complex or unusual claims for further review or investigation.
• Participate in ongoing training and professional development activities.
• Handle more complex claims with multiple services, providers

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