Claims Examiner Sr

Description

Status: Open
Department: Claims

Purpose: Processes contract and non-contract provider claims accurately and in a timely manner, meeting established Department and Company guidelines for quantity, turnaround time and accuracy.

Responsibilities:
Generates correspondence to request missing information necessary to complete claim payment and appropriate letters for denied claims. Determines level of reimbursement based on established criteria, provider contract or plan provisions. Denies all claims ineligible for payment. Enters coding information. Documents provider claims/system support payments and decisions. Identifies dual coverage, potential third party liability cases, and reinsurance/stop loss cases and requests additional information relevant to SCAN savings/recovery. Reviews claims for possible abuses of SCAN/delivery systems and brings issues to attention of management. Coordinates workflow with clerical support and other staff members.

Requirements

Minimum 2 years claims processing experience in the health insurance industry or medical health care delivery system. Completion of health insurance training and medical terminology or equivalent knowledge through on-the-job training and experience. Knowledge of standard claims coding such as CPT4, ICD9, DRG and HCPCS. Knowledge of coordination of benefits and NAIC guidelines preferred. Ability to type 45-50 wpm and operate a 10 key in order to meet production goals. Knowledge of heath care benefit structures and insurance procedures, preferably as they exist in an HMO health care environment. Knowledge of an automated claims processing system and ability to use CRT. Intermediate to advanced expertise using Microsoft products such as Word, Excel and Access. Previous experience using an on-line claim payment system. Strong verbal and written communication skills.

Education:
High school graduate; 2 years college preferred.

SCAN is an Equal Opportunity Employer