Claims Examiner

Responsible to review, analyze and research health care claims using the necessary tools such as a review of provider contracts, pricing, benefits, CES edits, NCCI edits, correct coding, applying other carrier payments, and other appropriate tools in order to identify discrepancies, and process them for payment. This role is responsible to ensure that claims are processed according to state and federal regulations and meet the companys contractual obligations. Collaborate with business and operational units such as Quality Control, Reconsideration Specialist, Special Investigations Unit (SIU), and Documentation Specialist to ensure proper and cohesive claims understanding.

Duties and Responsibilities

Responsibilities include, but are not limited to the following:

• Responsible for the entry, review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms
• Must meet established department production and quality standards
• Investigate and release low to high complexity claims including Transplants and those with Single Case Agreements
• Review and approve high dollar claims within established threshold and route to other levels as required by the approval process
• Process and reconcile SIU requests
• Responsible for the data integrity and accuracy of manually entered claims
• Responsible for generating requests for additional information required to process a claim (i.e., incomplete authorization information, requesting a new provider number)
• Responsible to determine if correct billing/coding requirements have been met
• Process claims subject to COB (Coordination of Benefits) according to plan benefits, COB rules and contractual reimbursement terms
• Responsible for the processing of employee claims (VIP) with strict confidentiality
• Perform retroactive adjustment projects
• Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, benefit plan documents, etc)
• Support various claims scanning functions
• Support claim batching process
• Follow daily schedule of assigned duties
• Identify and communicate claims system and/or billing problems to the departments management
• Complete daily activity logs
• Assist in training of other claims staff as needed
• Attend staff meetings
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Core Company-Wide Competencies:

• Communicate Effectively
• Respect Others & Value Diversity
• Analyze Issues & Solve Problems
• Drive for Customer Success
• Manage Performance, Productivity & Results
• Develop Flexibility & Achieve Change

Job Specific Competencies:

• Collaborate & Foster Teamwork
• Attend to Detail & Improve Quality
• Exercise Sound Judgement & Decision Making

FDR Oversight: N/A

Flexible Work Arrangement:

• Yes

Telecommuting Arrangement:

• No

Travel Expectations:

• N/A

Qualifications

Required:

• High School graduate or equivalent
• Strong verbal and written communications skills
• Demonstrated mathematical skills with attention to detail
• Ability to work both independently and as a team member
• Experience with Microsoft Word and Excel
• Ability to effectively prioritize and execute tasks in a production environment
• Ability to meet production and quality standards
• Minimum of two (2) years claims processing or medical billing experience
• Knowledge of industry standard coding and medical terminology

Preferred:

• Associates Degree
• Experience within claims operations in a Health Care environment
• Coding certification from the American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA)

Salary Grade: D

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.