Claims HMO - Senior Claims Examiner

JOB SUMMARY:

The Senior Claims Examiner is responsible for reviewing and examining claims that require additional analysis prior to adjudication. Using established resources, technical knowledge, and sound judgment, the Senior Claims Examiner determines the appropriate action to pay, deny, or adjust claims while meeting established standards for accuracy, productivity, and efficiency.

The Senior Claims Examiner typically handles more complex claims involving multiple lines of business and/or assumes additional, ongoing responsibilities beyond those associated with general claims examination.

KEY RESPONSIBILITIES:

• Examine and adjudicate complex or specialized claims that have pended for review across multiple lines of business by applying applicable benefit provisions, processing guidelines, reimbursement methodologies, and sound judgment to determine appropriate claim outcomes.
• Enter and validate claim information in processing systems to determine payments, allowable amounts, benefit limitations, exclusions, and denials.
• Identify, document, and communicate trends, processing issues, or recurring problems observed during claim adjudication.
• Resolve unique or complex claims situations independently and determine when escalation to a team lead, supervisor, or other department is appropriate.
• Identify, document, and communicate trends, processing issues, or recurring problems observed during claim adjudication.
• Maintain current knowledge of changes to claims processing procedures, benefit provisions, limitations, regulatory requirements, and applicable guidelines, and adapt processes accordingly.
• Assist with training, mentoring, and development of Claims Examiners; Serve as a resource by providing guidance on claims processing procedures, benefit provisions, system functionality, and complex claim scenarios.
• Perform other job-related duties as required or assigned.

QUALIFICATIONS:

• Self-motivated and able to work independently with minimal direction.
• Ability to interpret and apply claims processing manuals, medical terminology, CPT codes, and established processing procedures.
• Ability to read, interpret, and apply information contained in health benefit booklets.
• Demonstrated learning agility and ability to adapt to changing processes, systems, and requirements.
• Knowledge of contracted managed care plan terms, provisions, and reimbursement rates for multiple lines of business.
• General knowledge of unbundling practices, coordination of benefits (COB), and other potential overbilling methodologies.
• Strong attention to detail and commitment to accuracy.
• Proficiency with Microsoft Office applications.
• Ability to perform basic mathematical calculations accurately.
• Strong verbal and written communication skills.
• Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE:

• High School Diploma or Equivalent required.
• A minimum of two years of experience in medical claims processing.