Medical Claims Examiner Job Description

Medical Claims Examiner Job Description

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Medical claims examiner provides onsite coding and documentation education and feedback to providers for coding changes (CPT including E&M, modifiers and internal codes, ICD-9, ICD-10, HCPCS), annual updates, payer requirements and insurance rejection resolution.

Medical Claims Examiner Duties & Responsibilities

To write an effective medical claims examiner job description, begin by listing detailed duties, responsibilities and expectations. We have included medical claims examiner job description templates that you can modify and use.

Sample responsibilities for this position include:

Interpret and apply specific plan document language determine eligibility for benefits during claims adjudication
Provide responsive and professional customer service for assigned groups other groups with Client as needed
Under supervision, you will be responsible for processing complex claims requiring further investigation, including coordination of benefits, and resolving pended claims
Review and compare information in computer systems and apply proper codes/documentation
May place outgoing calls to providers and/or pharmacies for further investigation before processing claims
Of the Technical Claims Managers, as needed
Must possess a general understanding of all products and services
Comply with all quality control standards set by the company for the handling of claims
They work on routine and nonroutine matters
They handle routine questions and issues, referring complex or unexpected matters to higher level employees for assistance

Medical Claims Examiner Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Medical Claims Examiner

List any licenses or certifications required by the position: CPC

Education for Medical Claims Examiner

Typically a job would require a certain level of education.

Employers hiring for the medical claims examiner job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Education, Medical, Law, Associates, Legal, Communication, Graduate Education, Business/Administration, Health, Business

Skills for Medical Claims Examiner

Desired skills for medical claims examiner include:

Claims handling and settlement procedures in the California Workers’ Compensation system
CPT
HCPC
Experience with Medicare Part D
HMO
ICD-10 codes
ICD-9
Medical terminology
PPO Medicare and Medicaid plans
AMISYS

Desired experience for medical claims examiner includes:

Similar experience with an equivalent self-insured trust, captive insurer, or physician indemnification program will also be considered
Investigate pre-suit claims related to low exposure medical malpractice, professional liability and general liability matters (dental injury, slip & fall, vehicular damages)
Medical and/ior legal experience required
Effective knowledge and understanding of professional liability claims handling protocols and processes
Strong computer skills with proficiency in Microsoft Office software
Travel includes your hourly wage, plus a weekly per diem, and all travel/hotel/rental car expenses covered in full up front (no out of pocket to you)

Medical Claims Examiner Examples

1

Medical Claims Examiner Job Description

Job Description Example
Our innovative and growing company is looking for a medical claims examiner. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for medical claims examiner
  • Involved in fact finding, information search and data gathering
  • Identifies and resolves routine and recurring problems
  • Batch and prioritize a minimum of 175 IPA claims processing per day utilizing the company’s in - house claims processing system
  • Establishes proof of loss by reviewing medical documentation presented, requesting additional information from sources such as administrators, brokers, hospitals, physicians
  • Reviews claims using a variety of file/information formats of multiple TPAs, interpreting and comparing contracts, dispersing reimbursements, and ensuring that all claims contain the required documentation to support the Stop Loss claim determination
  • Adjudicates claims in medical Stop Loss system and approves or denies based on compliance with the SPD and the Stop Loss policy
  • Sets financial risk reserves for each Stop Loss claim filed
  • Applies the appropriate contractual provisions associated with assigned Stop Loss claims including plan specifications of the underlying plan document and professional case management resources
  • Claims practices, procedures and protocols to the medical facts of each claim to decide on reimbursement or denial of a claim
  • Develops, coordinates and implements a plan of action for each claim accepted to ensure it is managed effectively and all cost containment initiatives are implemented in conjunction with the clinical resources
Qualifications for medical claims examiner
  • Sound comprehension of coverage provided by healthcare related insurance policies
  • Ability to manage litigation, to establish loss and expense reserves and to evaluate issues of liability and damages in assigned matters
  • Ability to self-manage a high caseload through the use of creative and critical thinking
  • Ability to analyze complex issues and to convey summations of same to Managers and Director
  • Travel required as necessary (approximately 20%)
  • 1-2 years of experience minimum, processing and adjudicating medical claims required and experience independently reviewing simple to moderately complex claims for adjudication purposes in a managed care environment
2

Medical Claims Examiner Job Description

Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of medical claims examiner. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for medical claims examiner
  • Conducting investigations into claimant health history through review of medical records and billing documentation
  • Interpreting insurance contract benefits and definitions
  • Making decisions about claim payments and claimant eligibility
  • This level is responsible for reviewing routine claims for adjudication purposes
  • Adjusts medical-only claims and low- to mid-level lost-time workers compensation claims under close supervision
  • Supports other claims staff with larger or more complex claims as necessary
  • Processes workers compensation claims reviewing compensability, benefits due, and files necessary documentation with state agency
  • Ensures claims files are properly documented and claims coding is correct
  • Coordinates actuarial/settlement issues impacting employers with rate and settlement departments
  • 25% - Provides guidance on and applies law to administer workers' compensation claims in compliance with all rules, regulations and reporting requirements of the Labor Code, Division of Workers' Compensation, Self-Insurance Regulations, OSHA, and other administrative laws
Qualifications for medical claims examiner
  • Investigative experience in corporate risk exposure required
  • College degree and/or professional designation required, JD preferred
  • SIP WCCA/WCCP Preferred
  • Claims Examiner Designation required
  • The candidate must have the ability to prioritize multiple tasks, meet deadlines and provide excellent customer service
  • Requires 4+ years of healthcare / medical claims examiner experience
3

Medical Claims Examiner Job Description

Job Description Example
Our growing company is looking for a medical claims examiner. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for medical claims examiner
  • 25% - Reviews and approves benefits payable to injured employee and invoices including, medical provider bills, liens and mileage
  • 15% - Acts as an information resource to employees, supervisors, and internal and external contacts
  • 5% - Visits local bases to discuss case strategy with local management
  • 5% - Perform other duties as assigned (no more than 5% of duties)
  • Receives client submissions and inputs client and examinee data in the system database
  • When necessary, works with transcriptionists and/or physicians’ offices regarding report details, clarification, Addendums
  • Ensure all medical records/reports are properly documented and saved in the system
  • Responsible for editing and adjusting of EDI claims
  • Adherence to client protocls York operating definitions
  • Follows claims adjudication process, within the claims transactional system, to assure that all claims are adjudicated in accordance with CMS rules and regulations, in accordance with contractual obligations/timelines
Qualifications for medical claims examiner
  • CA Self Insurance Certificate
  • 3+ years of experience working as a Healthcare / Medical "Claims Examiner"
  • Requires 3+ solid years of experience working as a Healthcare / Medical "Claims Examiner"
  • Requires 3+ solid years’ continuous experience working as a Healthcare/Medical “Claims Examiner”
  • At least 4 years of experience in examining Industrial Claims
  • Good knowledge of software programs Windows and MS Office applications
4

Medical Claims Examiner Job Description

Job Description Example
Our innovative and growing company is hiring for a medical claims examiner. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for medical claims examiner
  • Researches and investigates high complexity claims to determine if claims are both payable to our providers and invoiceable to our contractor in accordance with various policy provisions
  • Responsible for generating requests for additional information required to process a claim (i.e., incomplete authorization information, processing new provider and vendors)
  • Responsible to determine if correct billing/coding requirements have been met
  • Verifies payment and invoicing amounts are accurate, by analyzing claim extracts and utilizing systems, tools and resources available
  • Performs routine and random sampling audits of adjudicated claims to identify inaccurate claims adjudication
  • Researches, trouble shoot and resolve errors and problem areas in claims entry and processing
  • Identifies prevalent trends for inaccurate claims processing and adjudication
  • Assists in the development of action plans to address quality deficiencies
  • Works with community-based providers to stimulate the billing process by reviewing records to maintain documentation of outstanding charges
  • Identifies and communicates claims system and/or billing problems to Manager
Qualifications for medical claims examiner
  • 3 years Professional and Institutional Claims experience
  • Requires 3+ years experience working as an actual “Claims Examiner” in a Managed Care environment
  • 3 years of experience working with various fee schedules (i.e., CMS, Medical)
  • 10 years claims adjudication
  • Two or more years managed care experience in Prior Authorization or Claim Review
  • 3-5 years nursing experience or other equivalent hands-on medical industry experience
5

Medical Claims Examiner Job Description

Job Description Example
Our growing company is hiring for a medical claims examiner. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for medical claims examiner
  • Analyses workflow to meet claims KPIs and targets
  • Supports claims payment and invoicing batching process
  • Analyzes and processes claim forms (UB-04 and CMS-1500) and reviews Medicare services for appropriateness of charges
  • Follows claims adjudication process to assure that all claims are adjudicated in accordance with CMS rules and regulations
  • Liaisons with staff responsible for daily transactional and business operations
  • Able to work and adjust priorities in a fast-paced environment
  • Evaluate claim material to determine eligibility
  • Ensure policy benefits are paid accurately, if applicable
  • Apply benefits on every applicable policy
  • Request additional information when required
Qualifications for medical claims examiner
  • Intermediate knowledge of medical prognoses and treatment
  • Experience using Microsoft Word and Excel (Intermediate Knowledge)
  • Highest standards of accuracy / attention to detail
  • Highest standards of accuracy and attention to detail
  • Nevada Staff Adjuster license required OR willingness to obtain license within 30 days of hire
  • Proficiency with 10 key typing skills

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