Claims Examiner I - New York, NY

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

Job summary

MetroPlus is seeking a Claims Examiner I to enter data and adjudicate provider claims, ensuring accurate and timely disposition within guidelines.

The role involves reviewing service descriptions, applying processing policies, and communicating with providers to obtain necessary information, while maintaining quality metrics and production goals. Strong knowledge of CPT/ICD, revenue codes, and healthcare terminology is preferred and required to meet departmental standards.

Qualifications

• Associate’s Degree required and minimum 2 years’ experience in healthcare insurance with knowledge of integrated claims processing.
• Proficiency with data entry skills.
• Through 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, e.g., maintaining individual production counts, updating manuals and reference materials, attending refresher training seminars.

Skills

Data entry

Claims processing

Medical terminology

CPT/ICD-P 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
• Authorizes the generation of letters/questionnaires to providers to obtain additional information
• Reviews descriptions of services on claims to determine validity of charges of the 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; and
• 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