Claims Examiner II

Doctors HealthCare Plans, Inc.; Coral Gables (FL); Sur place; USD 42 000 - 62 000; Plein temps

Résumé du poste

Doctors HealthCare Plans, Inc. in Florida is seeking a Claims Examiner to provide expertise in reviewing, researching, processing and adjusting health claims across multiple applications and platforms.

You will ensure proper benefits are applied to each claim, communicate clearly with internal departments, stay current with CMS guidelines and AHCA regulations, and strive to meet high-quality and production performance goals.

Qualifications

• 1–3 years of health claims processing experience.
• Working knowledge of COB and MSP preferable.
• Medical terminology and computer literacy required.
• Knowledge of CMS, AHCA and other federal/state guidelines is essential.
• Excellent organizational skills and ability to work under pressure.

Responsabilités

• Review, research, analyze and process professional claims by navigating multiple applications.
• Ensure the proper benefits are applied to the claim using CMS guidelines.
• Communicate with internal departments using clear, simple language.
• Keep up to date with system updates and new applications.
• Meet and maintain performance goals for quality and production.

Connaissances

Excellent oral and written comms

Health claims processing

Medical terminology

Computer literacy

CMS/AHCA guidelines knowledge

Organizational skills

Ability to work under pressure

Formation

High School Diploma or GED

Description du poste

Position Purpose

The Claims Examiner is responsible for providing expertise and/or claims support in reviewing, researching, investigating, processing and adjusting claims and other duties as necessary.

Key Responsibilities

• Review, research, analyze and process professional claims by navigating multiple applications and platforms accurately.
• Ensure that the proper benefits are applied to the claim using the appropriate tools (e.g. CMS guidelines).
• Communicate with internal departments using clear, simple language to ensure understanding.
• Keep up via training with system updates and new applications.
• Meet and maintain the performance goals as established for the position in the area of quality and production.

Qualifications

• High School Diploma or GED
• Excellent oral and written communication skills
• 1 – 3 years of Health claims processing experience
• Working knowledge of COB and MSP preferably
• Medical terminology
• Computer literacy
• Knowledge of current Medicare Advantage operational and regulatory guidelines established by CMS, AHCA and other federal and state regulatory guidelines.
• Excellent organizational skills
• Ability to work well under pressure and difficult situations

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team meber(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.