Claims Examiner Senior - Health Plan Claims Processing

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.

Responsibilities:

* Meets expectations of the applicable OneCHRISTUS 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, and federal regulations.
* Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc.
* Work claim projects resulting from overpayments or underpayments related to manual processing errors, benefit updates, and/or contract, fee schedule changes.
* Process provider refunds, reconsiderations, and direct member reimbursements.
* Process medical claim adjustments, recovery of claim overpayments, and execution of claim batch adjudication.
* Solve moderately complex claims and escalate issues to the Claims Team Lead, Supervisor or Manager.
* Assist with database improvements and testing for system upgrades, conversions, or implementation of new processes.
* Serves as a resource to assist with training new associates, retraining current associates on new/updated desktops/policies and reports staff progress, deficiencies, and training needs to management.
* Sets high standards of performance and promotes teamwork to achieve established team goals, while maintaining a positive, professional attitude.
* Contacting/responding to internal and external customers for resolution on claim issues.
* Assist claims leadership to identify claim trends, gaps in workflow and create/update desktops and policies and procedures.
* Collaborate with and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate completion of tasks/goals.
* Must be able to organize and prioritize work to meet deadlines.
* Have good judgment, initiative, and problem-solving abilities.
* Attention to detail is critical to ensure timely and accurate processing of claims.
* Consistently meet established productivity and quality standards.
* Follow CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI).
* Performs other duties as assigned by management to support claims functions, which are focused on achieving both departmental and organizational objectives.
* Must be knowledgeable about medical terminology, CPT, HCPCS, ICD-10, Revenue Codes, CMS-1500 and CMS-1450/UB-04 claim forms and reimbursement methodologies.
* Must have excellent written, verbal, organizational and interpersonal communication skills.
* Must be proficient in Microsoft Office, Power Point, Excel, Word, Outlook, spreadsheet, and database skills.

Job Requirements:

Education/Skills
* Associate's degree or equivalent job-related 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.

Licenses, Registrations, or Certifications
* None required

Work Schedule:

TBD

Work Type:

Full Time

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