Claims Examiner
Description
Responsible to review, analyze and research health care claims using the necessary tools such as a review of provider contracts, pricing, benefits, CES edits, NCCI edits, correct coding, applying other carrier payments, and other appropriate tools in order to identify discrepancies, and process them for payment. This role is responsible to ensure that claims are processed according to state and federal regulations and meet the companys contractual obligations. Collaborate with business and operational units such as Quality Control, Reconsideration Specialist, Special Investigations Unit (SIU), and Documentation Specialist to ensure proper and cohesive claims understanding.
Duties And Responsibilities
Responsibilities include, but are not limited to the following:
Responsible for the entry, review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms
Must meet established department production and quality standards
Investigate and release low to high complexity claims including Transplants and those with Single Case Agreements
Review and approve high dollar claims within established threshold and route to other levels as required by the approval process
Process and reconcile SIU requests
Responsible for the data integrity and accuracy of manually entered claims
Responsible for generating requests for additional information required to process a claim (i.e., incomplete authorization information, requesting a new provider number)
Responsible to determine if correct billing/coding requirements have been met
Process claims subject to COB (Coordination of Benefits) according to plan benefits, COB rules and contractual reimbursement terms
Responsible for the processing of employee claims (VIP) with strict confidentiality
Perform retroactive adjustment projects
Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, benefit plan documents, etc)
Support various claims scanning functions
Support claim batching process
Follow daily schedule of assigned duties
Identify and communicate claims system and/or billing problems to the departments management
Complete daily activity logs
Assist in training of other claims staff as needed
Attend staff meetings
Other duties as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
Core Company-Wide Competencies:
Communicate Effectively
Respect Others & Value Diversity
Analyze Issues & Solve Problems
Drive for Customer Success
Manage Performance, Productivity & Results
Develop Flexibility & Achieve Change
Job Specific Competencies:
Collaborate & Foster Teamwork
Attend to Detail & Improve Quality
Exercise Sound Judgement & Decision Making
FDR Oversight: N/A
Flexible Work Arrangement:
Yes
Telecommuting Arrangement:
No
Travel Expectations:
N/A
Qualifications
Qualifications
Required:
High School graduate or equivalent
Strong verbal and written communications skills
Demonstrated mathematical skills with attention to detail
Ability to work both independently and as a team member
Experience with Microsoft Word and Excel
Ability to effectively prioritize and execute tasks in a production environment
Ability to meet production and quality standards
Minimum of two (2) years claims processing or medical billing experience
Knowledge of industry standard coding and medical terminology
Preferred:
Associates Degree
Experience within claims operations in a Health Care environment
Coding certification from the American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA)
Salary Grade: D
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Apply Now
Responsible to review, analyze and research health care claims using the necessary tools such as a review of provider contracts, pricing, benefits, CES edits, NCCI edits, correct coding, applying other carrier payments, and other appropriate tools in order to identify discrepancies, and process them for payment. This role is responsible to ensure that claims are processed according to state and federal regulations and meet the companys contractual obligations. Collaborate with business and operational units such as Quality Control, Reconsideration Specialist, Special Investigations Unit (SIU), and Documentation Specialist to ensure proper and cohesive claims understanding.
Duties And Responsibilities
Responsibilities include, but are not limited to the following:
Responsible for the entry, review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms
Must meet established department production and quality standards
Investigate and release low to high complexity claims including Transplants and those with Single Case Agreements
Review and approve high dollar claims within established threshold and route to other levels as required by the approval process
Process and reconcile SIU requests
Responsible for the data integrity and accuracy of manually entered claims
Responsible for generating requests for additional information required to process a claim (i.e., incomplete authorization information, requesting a new provider number)
Responsible to determine if correct billing/coding requirements have been met
Process claims subject to COB (Coordination of Benefits) according to plan benefits, COB rules and contractual reimbursement terms
Responsible for the processing of employee claims (VIP) with strict confidentiality
Perform retroactive adjustment projects
Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, benefit plan documents, etc)
Support various claims scanning functions
Support claim batching process
Follow daily schedule of assigned duties
Identify and communicate claims system and/or billing problems to the departments management
Complete daily activity logs
Assist in training of other claims staff as needed
Attend staff meetings
Other duties as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
Core Company-Wide Competencies:
Communicate Effectively
Respect Others & Value Diversity
Analyze Issues & Solve Problems
Drive for Customer Success
Manage Performance, Productivity & Results
Develop Flexibility & Achieve Change
Job Specific Competencies:
Collaborate & Foster Teamwork
Attend to Detail & Improve Quality
Exercise Sound Judgement & Decision Making
FDR Oversight: N/A
Flexible Work Arrangement:
Yes
Telecommuting Arrangement:
No
Travel Expectations:
N/A
Qualifications
Qualifications
Required:
High School graduate or equivalent
Strong verbal and written communications skills
Demonstrated mathematical skills with attention to detail
Ability to work both independently and as a team member
Experience with Microsoft Word and Excel
Ability to effectively prioritize and execute tasks in a production environment
Ability to meet production and quality standards
Minimum of two (2) years claims processing or medical billing experience
Knowledge of industry standard coding and medical terminology
Preferred:
Associates Degree
Experience within claims operations in a Health Care environment
Coding certification from the American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA)
Salary Grade: D
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Apply Now