The Claims Examiner I 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 I 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.
- 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 document
- 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
Job Status: Full Time