Job Description

Job Summary

 

The Claims Examiner adjudicates incoming claims in accordance with policies, procedures and guidelines, as outlined by Leon Health and contractual agreements; within mandated timeframes; and according to rates as reflected in respective provider contracts. The Claims Examiner will be responsible for adjudicating claims from a variety of medical specialties in a timely manner to maintain turnaround time regulatory requirements.

 

Summary of Essential Duties and Responsibilities

 

  • Enter claim data accurately and timely, in alignment with departmental production and quality goals
  • Manually price and adjudicate claims as needed.
  • Maintain a minimum of 98% accuracy at all times
  • Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with MBA contractual guidelines
  • Ensure claims payments are made within time frames as reflected in contractual agreements
  • Identify and refer potential fraud and abuse cases to the Compliance Department
  • Other duties and responsibilities as may be assigned.

 

 

Minimum Requirements

 

  • High School diploma or GED equivalent
  • Minimum of two years’ experience in healthcare claims processing, medical billing or an equivalent combination of education, training and experience
  • Computer proficiency in a Windows environment, knowledge of Microsoft Office products with an emphasis in Excel.
  • Detailed knowledge of electronic billing processes and universal billing forms (UB04, CMS-1500)
  • Strong knowledge of medical terminology
  • Knowledge of CPT Codes and HCPCs codes
  • Knowledge of ICD-10 coding
  • HIPAA regulations
  • Medicaid and Medicare claim processing experience a plus
  • Ability to read and interpret general business correspondence, procedure manual, and specific plan documents

 

 

Abilities Required

 

  • Ability to manage multiple tasks and prioritize work to adhere to deadlines and identified time frames
  • Ability to read, write and communicate at a professional level
  • Effective time management and organizational skills
  • Effective interpersonal and communication skills