The primary responsibility of the Claims Examiner is to process incoming claims for his or her assigned insurance programs and to become an expert on each school’s benefits, provider health services networks, and procedures that are unique to each program. It is critical that each examiner places emphasis on accuracy, customer service, and accountability of their work. The examiner is also responsible for serving as the claims representative for school administrators.
- Manages and prioritizes workload to be in compliance with the Company’s commitments to their clients
- Reviews claims, researches insured/claimant’s records to identify any third-party liability and approves or denies payment as appropriate
- Adjudicates claims using Company guidelines and the carrier/school benefit schedules, including the utilization of re-pricing networks, UCR values, etc.
- Requests additional information to validate claims from providers, insured/claimants, and schools/colleges, verifies claim calculation
- Documents files and records of pending actions
- Identifies and notifies appropriate Company officials of problems with the claims system
- Reviews production, benchmarks and errors with supervisor periodically
- Meets or exceeds accuracy and production level standards
- Provides customer service and serves by answering incoming calls when applicable from insureds, providers, and school representatives. Assists with claims issues, claims status and benefits.
- If applicable, handles foreign language calls using company LAP (Language Assistance Program) procedures
- Initiates calls to ascertain the validity of a claim or to gather additional information in order to process or deny claims
- Responds to Auditor findings in a timely manner
- Generates letters to insureds and providers as appropriate
- Performs other duties and special projects as assigned
- Ability to read, analyze and interpret company guidelines and benefit documentation, or government regulations
- Ability to calculate figures and amounts such as discounts, interest and percentages
- Intermediate personal computer skills including electronic mail, routine database activity, word processing, spreadsheets, etc.
- Enthusiastic, dependable, highly motivated and detail oriented
- Hands-on, open minded, proactive team player
- Self-managed and responsible time management
- Customer focused, high integrity, excellent work ethic
- Excellent customer service skills are a must
- Willingness to adhere to all principles of confidentiality
- Must value operating in a collaborative work environment
- Ability to handle multiple tasks simultaneously
- Working knowledge of the laws and regulations associated with HIPAA
EDUCATION AND QUALIFICATIONS
- High School diploma or its equivalent
- College degree preferred or comparable work experience
- 1+ years’ medical health claims experience preferred