Medical Claims Examiner

Summary
The Claims Examiner Senior is responsible for reviewing analyzing researching and resolving complex medical claims in accordance with claims processing guidelines and desktops as well as ensuring compliance with federal regulations. This role works in conjunction with Business Configuration Network Management Provider Data Complaints Appeals and Grievances as well as other operational departments to ensure validation and quality assurance of claims processing.
Roles & Responsibilities
Responsibilities:
Meets expectations of the applicable One clients Competencies: Leader of Self Leader of Others or Leader of Leaders.
Analyze medical claim information and take appropriate action for payment resolution in accordance with policies and procedures desktops processing guidelines


Minimum Qualifications
Job Requirements: Education/Skills
Associates degree or equivalent jobrelated experience required.
Experience
Minimum of 3 years experience processing medical claims in the healthcare industry.
Prior experience working with managed care Medicare Medicare Advantage Health Exchange and TRICARE are highly desirable.
Process medical claims submitted on CMS1500 and CMS1450/UB04 claim forms from facilities physicians Home Health Durable Medical Equipment providers laboratories etc.