Job Description
Summary: The Claims Examiner I is responsible for ensuring claims are coded and processed correctly and for meeting production requirements. Processes claims by performing the following duties.
***This is Not a Remote Position****
Essential Duties and Responsibilities include the following. Other duties may be assigned.
- Compares data on claims with internal policy and other company records to ascertain completeness and validity of claims.
- Comprehensive understanding of employee benefits for medical, dental and vision plans.
- Ensures all claims are coded properly.
- Examines Summary Plan Documents, claim adjustors' reports or similar claims/precedents to determine the extent of coverage and liability.
- Maintains high quality standards to avoid paying claim incorrectly.
- Maintains productivity standards set by Management.
- Refers most questionable claims for the investigation to claim examiner II for review and processing.
- Research and resolve paid and denied claims escalations from internal sources and/or TIPS ticketing system when assigned.
- Works with the claims queue manager to process & release claims for adjudication and payment within 3-5 days of receipt.
- Performs other duties and responsibilities as assigned by Management.
Knowledge, Skills, & Abilities
- Excellent written and verbal communication skills.
- Strong analytical skills and problem-solving skills.
- Must be dependable and maintain excellent attendance and punctuality.
- Must be able to perform data entry operations quickly and accurately.
- Ability to grow with changing demands of the position and the company.
- Strong computer skills, including Word, Excel, and Outlook.
- Must be highly proficient in ICD-10, CPT, and HCPCS codes.
Supervisory Responsibilities: This job has no supervisory responsibilities.
Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
Education and/or Experience: Associate's degree (A. A.) or equivalent from a two-year college or technical school; Must have 3-5 years of employee benefits industry experience or equivalent combination of education and experience.