Medical Claims Examiner Job Description
Medical Claims Examiner Duties & Responsibilities
To write an effective medical claims examiner job description, begin by listing detailed duties, responsibilities and expectations. We have included medical claims examiner job description templates that you can modify and use.
Sample responsibilities for this position include:
Medical Claims Examiner Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Medical Claims Examiner
List any licenses or certifications required by the position: CPC
Education for Medical Claims Examiner
Typically a job would require a certain level of education.
Employers hiring for the medical claims examiner job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Education, Medical, Law, Associates, Legal, Communication, Graduate Education, Business/Administration, Health, Business
Skills for Medical Claims Examiner
Desired skills for medical claims examiner include:
Desired experience for medical claims examiner includes:
Medical Claims Examiner Examples
Medical Claims Examiner Job Description
- Involved in fact finding, information search and data gathering
- Identifies and resolves routine and recurring problems
- Batch and prioritize a minimum of 175 IPA claims processing per day utilizing the company’s in - house claims processing system
- Establishes proof of loss by reviewing medical documentation presented, requesting additional information from sources such as administrators, brokers, hospitals, physicians
- Reviews claims using a variety of file/information formats of multiple TPAs, interpreting and comparing contracts, dispersing reimbursements, and ensuring that all claims contain the required documentation to support the Stop Loss claim determination
- Adjudicates claims in medical Stop Loss system and approves or denies based on compliance with the SPD and the Stop Loss policy
- Sets financial risk reserves for each Stop Loss claim filed
- Applies the appropriate contractual provisions associated with assigned Stop Loss claims including plan specifications of the underlying plan document and professional case management resources
- Claims practices, procedures and protocols to the medical facts of each claim to decide on reimbursement or denial of a claim
- Develops, coordinates and implements a plan of action for each claim accepted to ensure it is managed effectively and all cost containment initiatives are implemented in conjunction with the clinical resources
- Sound comprehension of coverage provided by healthcare related insurance policies
- Ability to manage litigation, to establish loss and expense reserves and to evaluate issues of liability and damages in assigned matters
- Ability to self-manage a high caseload through the use of creative and critical thinking
- Ability to analyze complex issues and to convey summations of same to Managers and Director
- Travel required as necessary (approximately 20%)
- 1-2 years of experience minimum, processing and adjudicating medical claims required and experience independently reviewing simple to moderately complex claims for adjudication purposes in a managed care environment
Medical Claims Examiner Job Description
- Conducting investigations into claimant health history through review of medical records and billing documentation
- Interpreting insurance contract benefits and definitions
- Making decisions about claim payments and claimant eligibility
- This level is responsible for reviewing routine claims for adjudication purposes
- Adjusts medical-only claims and low- to mid-level lost-time workers compensation claims under close supervision
- Supports other claims staff with larger or more complex claims as necessary
- Processes workers compensation claims reviewing compensability, benefits due, and files necessary documentation with state agency
- Ensures claims files are properly documented and claims coding is correct
- Coordinates actuarial/settlement issues impacting employers with rate and settlement departments
- 25% - Provides guidance on and applies law to administer workers' compensation claims in compliance with all rules, regulations and reporting requirements of the Labor Code, Division of Workers' Compensation, Self-Insurance Regulations, OSHA, and other administrative laws
- Investigative experience in corporate risk exposure required
- College degree and/or professional designation required, JD preferred
- SIP WCCA/WCCP Preferred
- Claims Examiner Designation required
- The candidate must have the ability to prioritize multiple tasks, meet deadlines and provide excellent customer service
- Requires 4+ years of healthcare / medical claims examiner experience
Medical Claims Examiner Job Description
- 25% - Reviews and approves benefits payable to injured employee and invoices including, medical provider bills, liens and mileage
- 15% - Acts as an information resource to employees, supervisors, and internal and external contacts
- 5% - Visits local bases to discuss case strategy with local management
- 5% - Perform other duties as assigned (no more than 5% of duties)
- Receives client submissions and inputs client and examinee data in the system database
- When necessary, works with transcriptionists and/or physicians’ offices regarding report details, clarification, Addendums
- Ensure all medical records/reports are properly documented and saved in the system
- Responsible for editing and adjusting of EDI claims
- Adherence to client protocls York operating definitions
- Follows claims adjudication process, within the claims transactional system, to assure that all claims are adjudicated in accordance with CMS rules and regulations, in accordance with contractual obligations/timelines
- CA Self Insurance Certificate
- 3+ years of experience working as a Healthcare / Medical "Claims Examiner"
- Requires 3+ solid years of experience working as a Healthcare / Medical "Claims Examiner"
- Requires 3+ solid years’ continuous experience working as a Healthcare/Medical “Claims Examiner”
- At least 4 years of experience in examining Industrial Claims
- Good knowledge of software programs Windows and MS Office applications
Medical Claims Examiner Job Description
- Researches and investigates high complexity claims to determine if claims are both payable to our providers and invoiceable to our contractor in accordance with various policy provisions
- Responsible for generating requests for additional information required to process a claim (i.e., incomplete authorization information, processing new provider and vendors)
- Responsible to determine if correct billing/coding requirements have been met
- Verifies payment and invoicing amounts are accurate, by analyzing claim extracts and utilizing systems, tools and resources available
- Performs routine and random sampling audits of adjudicated claims to identify inaccurate claims adjudication
- Researches, trouble shoot and resolve errors and problem areas in claims entry and processing
- Identifies prevalent trends for inaccurate claims processing and adjudication
- Assists in the development of action plans to address quality deficiencies
- Works with community-based providers to stimulate the billing process by reviewing records to maintain documentation of outstanding charges
- Identifies and communicates claims system and/or billing problems to Manager
- 3 years Professional and Institutional Claims experience
- Requires 3+ years experience working as an actual “Claims Examiner” in a Managed Care environment
- 3 years of experience working with various fee schedules (i.e., CMS, Medical)
- 10 years claims adjudication
- Two or more years managed care experience in Prior Authorization or Claim Review
- 3-5 years nursing experience or other equivalent hands-on medical industry experience
Medical Claims Examiner Job Description
- Analyses workflow to meet claims KPIs and targets
- Supports claims payment and invoicing batching process
- Analyzes and processes claim forms (UB-04 and CMS-1500) and reviews Medicare services for appropriateness of charges
- Follows claims adjudication process to assure that all claims are adjudicated in accordance with CMS rules and regulations
- Liaisons with staff responsible for daily transactional and business operations
- Able to work and adjust priorities in a fast-paced environment
- Evaluate claim material to determine eligibility
- Ensure policy benefits are paid accurately, if applicable
- Apply benefits on every applicable policy
- Request additional information when required
- Intermediate knowledge of medical prognoses and treatment
- Experience using Microsoft Word and Excel (Intermediate Knowledge)
- Highest standards of accuracy / attention to detail
- Highest standards of accuracy and attention to detail
- Nevada Staff Adjuster license required OR willingness to obtain license within 30 days of hire
- Proficiency with 10 key typing skills