Job description

CLAIM EXAMINER

Position Summary

Determining the proper payment (if any) of medical claims by group health plans, based upon specific knowledge and application of each client’s customized plan(s).

Essential Functions

Independently review and analyze health care claims for: 1) reasonableness of cost; 2) medically unnecessary treatment by physicians and hospitals; and 3) fraud.
Determine whether a health plan provides benefits in connection with the claim submitted and the level of benefits to be paid to the provider.
Review and understand the terms and conditions of each clients’ customized plans.
Understand and comply with all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
Request, review, and analyze any physician notes, hospital records or police reports.
Consult with other entities who can offer additional evaluation of a claim.
Process claims in the QicLink System.
Review, analyze and add applicable notes to the QicLink System.
Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com.
Review billed procedure and diagnosis codes on claims for billing irregularities.
Analyze claims for billing inconsistencies.
Review and analyze specific procedure and diagnosis codes for medical necessity.
Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
Review Suspended Claim Reports and follow up on open issues.
Assist and support other team members as needed and when requested.
Attend continuing education classes as required, including but not limited to HIPAA training.

EDUCATION

High School Diploma, College and Advanced Degrees Preferred
Continuing education in all areas affecting group health and welfare plans is required.

Experience & Skills

All applicants must have strong analytical skills and knowledge of computer systems and CPT and ICD-9 coding terminology.
Applicants must have a minimum of 5 years of medical claims analysis experience (including dental and vision claims analysis).

COMPETENCIES

Job Knowledge
Time Management
Accountability
Communication
Initiative
Customer Focus

PHYSICAL DEMANDS

Ability to work with computer-based programs for extended periods of time.

WORK ENVIRONMENT

Remote

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

Required profile