Claims Examiner at Health Source MSO

Job Description:

Claims Examiner will be responsible for adjudicating complex claims, manually and/or automatically price claims accurately, and identify billing issues.

 Responsibilities include, but not limited to:

• Analyze, research, and process and/or adjust claims with accurate use of procedures and ICD-10 codes under respective provider and member benefits based on:
  • Contractual agreement
  • Health Plan division of financial responsibility
  • Applicable regulatory legislature
  • Claims processing guidelines
  • Client group’s and company’s policies and procedures
• Review and process facility (UB-04) and professional (CMS-1500) claims.
• Process Medicare member claims based on DMHC and DHS regulatory legislature
• Respond and resolve providers’ and health plans’ inquires in a timely manner
• Review services for appropriate charges and apply authorization
• Monitor aging claims with reports to maintain timeliness
• Maintain quality and productivity standards
• Participate in special projects
• Works closely with Supervisor and reports any issues

Qualifications:

•         At least a high school diploma

•         Must have at least 3 years of applicable healthcare claims adjudication experience within a managed care industry

•         Must be familiar with ICD-10, HCPCS, CPT coding, APC, ASC, and DRG pricing.

•         Must be familiar with facility and professional claim billing practices.

•         Must have good written and communication skills.

•         Must be able to follow guidelines, multi-task, and work comfortably within a team-oriented environment.

•         Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and EZ-CAP. Knowledge in EZ-CAP 6X is a plus.

•         Familiar with SSRS is a plus.

•         Typing skills of at least 40 wpm.