Medical Claims Examiner
The Arizona Priority Care is seeking an extremely detail-oriented, precise and thorough Medical Claims Examiner to join our team. This individual works both independently and in conjunction with claim supervisor to adjudicate claims, respond to provider or client inquiries in an accurate, timely and courteous manner. The Examiner must be professional, possess a good work ethic and be a team player.
- Processing of paper/scanned and EDI claims by reviewing and inputting data into the claims payment system using standard policies, procedures and guidelines.
- Meeting production and quality standards set for the department. Correcting of errors given by the claims auditor.
- Forward claims to appropriate departments for Med Review, Eligibility, etc.
- Verification of coverage and contract interpretation.
- Pursues and follow up on open and pended claims within specified timeframe.
- Researches and investigates claims with multiple coverage and complexity to determine if claim is payable in accordance with various policy provisions. If payable, determine eligible payee(s) and payment amounts. If not payable, develop detailed letter of explanation based on policy provisions and claim documents.
- Strong communication, analytical, organizational and problem-solving skills.
- Excellent time management skills.
- Proficient with Microsoft applications (Word, Excel, Outlook) and database systems.
- Must be able to read and interpret documents such as processing and procedure manuals, medical terminology and claims rules and regulations to appropriately develop the claim.
- Ability to write routine correspondence and accurate data-entry skills.
- Must be able to identify and define problems; collect data; establish facts and draw valid conclusions.
- EZ-CAP Claims payment systems knowledge is a plus but not required.
- Must be able to interact with providers in a professional manner and be capable of high professional levels of communication
Minimum 3-5 years of medical claims processing experience in Managed Care. Strong experience and knowledge of Claims, Medicare/Medicaid guidelines, ICD-9, HCPCS / CPT coding, HCFA 1500’s & UB92’s.
High School diploma required. College degree preferred.