Senior Medical Claims Examiner

Responsibilities:

• Claims processing and claims examining of all incoming claims based on departmental procedures.

• Understand the knowledge of hospital and physician billing and collections, knowledge of Medicare A & B, Medicaid, Commercial and PPO claims processing
• Interpret, apply and comprehend policy terms, deductibles, coinsurance, copays and policy max
• Coding ICD 9 (ICD 10 helpful), knowledge of how to process claims, how to read and interpret policies, CPT codes, Hospital coding and UB 04, Correct Coding Initiative principles and

• Meets deadlines promised to clients for claims processing.
• Review and perform quality assessments of work being released to clients to ensure claims processing errors are kept at a minimum. Identify claims that should be audited by the Medical Team when the total charges exceed the pre-established Payerfusion criteria.

• Medicare Advantage plans, capitation plans, risk assessment process and payments
• Follow up on network pending claims to ensure that they are released meeting the deadlines.  Provide the client with updates when the claims are pending until the claim is released.

• Receive and register appeals/balance billing cases into the system (claim notes, image the documents in the patient’s file), spreadsheet and distribute according to department procedure.
• Review and determine, according to department procedure, how to resolve the appeal/balance billing.
• Provide continues update to both client and provider until appeal/balance billing case is closed.
• Handles Provider Statements/invoices by contacting the providers to request a complete claim form
• Performs other similar and related duties as needed.