Claims Examiner I

MetroPlusHealth; New York (NY); On-site; USD 52,000 - 72,000; Full time

Job summary

MetroPlusHealth in New York, NY seeks a Claims Examiner I to handle data entry and system adjudication of provider claims, ensuring accurate and timely disposition within guidelines.

The role requires attention to detail, knowledge of CPT/ ICD-p, and revenue codes, with at least an associate degree and 2 years in healthcare insurance claims; you will screen information, request additional data, and maintain production quotas.

Qualifications

• Associate’s degree required.
• Minimum 2 years’ experience in the healthcare insurance industry with knowledge of integrated claims processing.
• Proficiency with data entry skills.
• Thorough knowledge of medical terminology, CPT, ICD-p, and Revenue Codes.

Responsibilities

• Process claims involving medical and/or surgical services; screens for complete member/provider information.
• Apply administrative policies when necessary, utilizing the claims processing manuals.
• Authorize the generation of letters/questionnaires to providers to obtain additional information.
• Reviews descriptions of services on claims to determine validity of charges or presence of errors.
• Evaluates and examines claims pended by the system due to contractual and/or payment discrepancies.
• Maintains production and quality goals established for the department.
• Performs other related duties, i.e., maintaining individual production counts, updating manuals and reference materials, attending all refresher training seminars

Skills

Data entry

CPT/ICD coding

Revenue codes

Education

Associate’s degree

Job description

Position Overview

The Claims Examiner I is responsible for the data entry and system adjudication of provider claims. The incumbent authorizes final disposition of claims within prescribed guidelines in an accurate and timely manner.

Scope Of Role & Responsibilities

• Process claims involving medical and/or surgical services; screens for complete member/provider information
• Apply administrative policies when necessary, utilizing the claims processing manuals
• Authorize the generation of letters/questionnaires to providers to obtain additional information
• Reviews descriptions of services on claims to determine validity of charges or presence of errors
• Evaluates and examines claims pended by the system due to contractual and/or payment discrepancies
• Maintains production and quality goals established for the department
• Performs other related duties, i.e., maintaining individual production counts, updating manuals and reference materials, attending all refresher training seminars

Required Education, Training & Professional Experience

• Associate’s Degree required
• Minimum 2 years’ experience in the healthcare insurance industry with knowledge of integrated claims processing; or
• A satisfactory equivalent combination of education, training, and experience
• Proficiency with data entry skills
• Through knowledge of medical terminology, CPT, ICD-p, and Revenue Codes

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication