The Claims Examiner is responsible for accurately and consistently adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy. Process claims according to all CMS and DMHC guidelines. Investigate and complete open or pended claims. Meet production and quality standards.

Job Duties and Responsibilities:

• Responsible for efficiency standards for number claims completed and for accuracy of entries.
• Handles in a professional and confidential manner all correspondence.
• Supports core values, policies, and procedures.
• Acquires and adjudicates medical claims for processing; reviews scanned, EDI, or manual documents for pertinent data on claim for complete and accurate information.
• Acquires daily workflow via reports or work queue and incoming phone calls.
• Research claims for appropriate support documents.
• Analyzes and adjusts data, determines appropriate codes, fees and ensures timely filing and contract rates are applied.
• Responds and documents resolution of inquiries from internal departments.
• Assists Finance with researching provider information to resolve outstanding or stale dated check issues.
• Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases.

Experience:

Three (3) years of medical claims processing for Medicare and Commercial products and provider dispute resolution processing in an IPA, HMO and Hospital related setting required.

Three (3) years of experience with processing all types of specialty claims such as Chemotherapy, Dialysis, OB and drug and multiple surgery claims required.

Three (3) years of experience on an automated claims processing system (Epic Tapestry preferred) preferred.