Claim Examiner I

Position Overview

The Claim Examiner I is tasked with precise and prompt processing of healthcare claims within a managed care setting, emphasizing Dual Eligible Special Needs Plans (DSNP) and Medicare business lines. This entails applying various benefit plans, policies, and regulatory standards to ensure claims—including new, reprocessed, overturned disputes, and appeals—are managed correctly. Their role is key in ensuring compliance, payment accuracy, and satisfaction of both members and providers.

Key Responsibilities

• Assess and process medical claims according to Medicare and DSNP guidelines, policies, and benefit frameworks.
• Precisely adjudicate incoming day claims, applying benefits, coding regulations, and pricing models accurately.
• Handle reprocessing of claims following overturned disputes and appeals, adjusting as per latest regulatory requirements.
• Review and manage dispute claims and reconsiderations, incorporating necessary corrections and re-adjudications.
• Implement appeals-related claim changes in a timely and accurate manner.
• Interpret provider contracts, reimbursement methods, and fee schedules to guarantee correct payments.
• Ensure adherence to CMS, state laws, and internal protocols.
• Identify and escalate complex claims, system errors, or compliance concerns appropriately.
• Meet productivity and quality benchmarks, including turnaround times for all claim categories.
• Maintain clear, precise documentation of claim processing in system notes.
• Work collaboratively with Provider Relations, Appeals & Grievances, and Configuration departments to resolve claim issues.
• Engage in audits, quality assessments, and ongoing improvement initiatives.

Qualifications and Education

• Minimum education requirement is a high school diploma or equivalent; associate's or bachelor's degree is preferred.
• At least 2 to 4 years of experience in claims processing within managed care or health insurance environments.
• Strong familiarity with Medicare and DSNP claims handling, benefit application, and coordination of benefits.
• Experience in claims reprocessing, disputes, and appeals resolutions, including overturn scenarios.
• Knowledge of CPT, HCPCS, and ICD-10 medical coding systems.
• Understanding provider contracts and reimbursement methodologies.
• Highly analytical with excellent problem-solving capabilities and meticulous attention to detail.
• Ability to manage several tasks simultaneously in a fast-paced environment.
• Proficiency with claims management software and Microsoft Office tools.
• Preferred knowledge includes CMS regulations, audit requirements, experience with dual-eligible populations, and Medicare Part C claims processing.

Core Competencies

• Precision and detail orientation
• Compliance and regulatory awareness
• Critical analysis and effective decision-making
• Time management and task productivity
• Communication skills and team collaboration

Working Conditions and Physical Demands

• Typical work environment noise level is moderate.
• Work involves field interactions with patients, families, staff, visitors, and government officials under varied conditions.
• Physical activities include climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting (up to 25 pounds occasionally), fine finger dexterity, repetitive actions, talking, hearing, and visual acuity.
• Duty hours may shift based on business needs, requiring full-time commitment of 40 hours weekly including weekends and holidays as needed, with potential overtime during peak times.

Performance Metrics

• Completion of daily and monthly responsibilities.
• Attendance and punctuality adherence.
• Compliance with company policies and procedures.
• Ensuring workplace safety and security.
• Delivering high-quality work outcomes.

Additional Information

The employer reserves the right to modify this job description as business needs evolve. This document reflects key duties and skills expected but is not exhaustive. The role demands adaptability and prioritization skills with supervisory guidance as necessary.

Employee Confirmation

By acknowledging this description, the employee understands the role requirements and expectations during employment.