Job Description
The Claims Examiner I adjudicates incoming claims in accordance with policies, procedures and guidelines, as outlined by Leon Health and contractual agreements; within mandated timeframes; and according to rates as reflected in respective provider contracts. The Claims Examiner I will be responsible for adjudicating claims from a variety of medical specialties in a timely manner to maintain turnaround time regulatory requirements.
Summary of Essential Duties and Responsibilities
ย Enter claim data accurately and timely, in alignment with departmental production and quality goals
ย Manually price and adjudicate claims as needed.
ย Maintain a minimum of 98% accuracy at all times
ย Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with MBA contractual guidelines
ย determination.
ย Ensure claims payments are made within time frames as reflected in contractual agreements
ย Identify and refer potential fraud and abuse cases to the Compliance Department
ย Other duties and responsibilities as may be assigned.
Minimum Requirements
ย High School diploma or GED equivalent
ย Minimum of two yearsย experience in healthcare claims processing, medical billing or an equivalent combination of education, training and experience
ย Computer proficiency in a Windows environment, knowledge of Microsoft Office products with an emphasis in Excel.
ย Detailed knowledge of electronic billing processes and universal billing forms (UB04, CMS-1500)
ย Strong knowledge of medical terminology
ย Knowledge of CPT Codes and HCPCs codes
ย Knowledge of ICD-10 coding
ย HIPAA regulations
ย Medicaid and Medicare claim processing experience a plus
ย Ability to read and interpret general business correspondence, procedure manual, and specific plan document
Abilities Required
ย Ability to manage multiple tasks and prioritize work to adhere to deadlines and identified time frames
ย Ability to read, write and communicate at a professional level
ย Effective time management and organizational skills
ย Effective interpersonal and communication skills
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