Claims Examiner I

Job Summary:

The Claims Examiner I is responsible for ensuring claims are coded and processed correctly and for meeting production requirements.

Responsibilities:

• Compares data on claim with internal policy and other company records to ascertain completeness and validity of claim.
• Comprehensive understanding of employee benefits for medical, dental and vision plans.
• Ensures all claims are coded properly.
• Examines Summary Plan Document, claim adjustors' reports or similar claims/precedents to determine extent of coverage and liability.
• Maintains high quality standards to avoid paying claim incorrectly.
• Maintains productivity standards set by Management.
• Refers most questionable claims for investigation to claim examiner II for review and processing.
• Research and resolve paid and denied claims escalations from internal sources and/or TIPS ticketing system when assigned.
• Works from the claims queue manager to process & releases claims for adjudication and payment within 3-5 days of receipt.
• Performs other duties and responsibilities as assigned by Management.

Qualifications:

• Excellent written and verbal communication skills.
• Strong analytical skills and problem-solving skills.
• Must be dependable and maintain excellent attendance and punctuality.
• Must be able to perform data entry operations quickly and accurately.
• Ability to grow with changing demands of the position and the company.
• Strong computer skills, including Word, Excel, and Outlook.
• Must be highly proficient in ICD-10, CPT, and HCPCS codes.

Education:

Associate's degree (A. A.) or equivalent from two-year college or technical school;

Must have 3-5 years employee benefits industry experience or equivalent combination of education and experience