The Claims Examiner II accurately reviews, researches and analyzes professional, ancillary and institutional inpatient and outpatient claims.
Essential Functions and Responsibilities of the Job
Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines.
Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims.
Comprehensive knowledge of various fee schedules and CMS pricers for outpatient/inpatient institutional, ancillary and professional claims, including, but not limited to Medicare fee schedules, DRG, APC, ASC, SNF-RUG.
Ability to identify and report processing inaccuracies that are related to system configuration.
Process all types of claims, such as, HCFA 1500, outpatient/inpatient UB92, high dollar claims, COB and DRG claim
Reviews. processes and adjudicate claims for payment accuracy or denial of payment according to Department’s policy and procedures.
Processes all claims accurately conforming to quality and production standards and specifications in a timely manner.
Documents resolution of claims to support claim payment and/or decision.
Makes benefit determinations and calculations of type and level of benefits based on established criteria and provider contracts.
Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.
Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines.
Adjudication of Commercial and Medicare Advantage claims.
Ability to prioritize, multitask and manage claims assignment within department goals and regulatory compliance and with minimal supervision.
Ability to make phone calls to Provider/Billing offices when necessary based on department guidelines.
Requests additional information or follow up with provider for incomplete or unclean claims.
Ability to effectively communicate with External and Internal teams to resolve claims issues.
Ability to interact in a positive and constructive manner.