Lead Medical Claims Examiner

CONTACTS AND RELATIONSHIPS

The position interfaces with department management, department employees, and employees from other departments.The position also requires contact with participants and their families, business managers, other insurance companies, and healthcare providers (e.g. doctors and hospitals).

ESSENTIAL FUNCTIONS

Accurate and timely processing of delegated claims per regulatory and contractual guidelines.

Train new hire Medical Claims Examiners on how to process claims and navigate the V3 system.

Determine eligibility, medical necessity, reasonable and customary allowances, and appropriate coding.

Review policy booklet, medical reference books and insurance company guidelines to determine coverage of claims under the policy.

Coordinate the responses of all examiners on weekly reports that are submitted to the Plan by Blue Cross/Blue Card

Investigate and adjudicate complex claim requests and claims requiring special handling, such as adjustments and complaints in accordance with Plan guidelines, policy contract language and departmental processes and standards.

Research and respond to participant/provider inquiries submitted to the department and report any issues to the appropriate supervisor.

Run weekly claims reports and delegate a portion of the report to Claims Examiners accordingly. Follow up with the examiners to ensure timely responses.

Write letters to participants and providers requesting additional information when necessary.

Follow-up on pending claims.

Work with Eligibility Department to resolve eligibility problems, add or delete dependents, address changes, etc.

Act in accordance with all HIPAA Privacy and Security guidelines to ensure confidential handling of protected health information.

Answer phone calls from participants and providers when necessary.

Regular, predictable, and reliable attendance is required.

Ability to accept direction and developmental guidance from supervisor.

Ability to work effectively with individuals at all levels.

SKILLS AND ABILITIES

• Extensive knowledge of medical terminology, ICD9, ICD10, and CPT codes.
• Extensive knowledge of Plan benefits, group insurance, and Medicare principals.
• Knowledge of Coordination of Benefits rules.
• Considerable knowledge of basic math.
• Ability to maintain production standards in a detail-oriented, quality-conscious service environment.
• Ability to work independently with minimal supervision.
• Strong analytical abilities.
• Good written and verbal communication skills.

EDUCATION AND EXPERIENCE

High school diploma with some college plus three years or more experience in health claims processing preferred.

PHYSICAL REQUIREMENTS

Possess manual dexterity sufficient to operate standard office machines.Ability to sit for extended periods of time.Position requires bending, reaching, walking, and lifting of up to 10 lbs.

STATUS

Non-Exempt