Medical Claims Examiner

SNI Companies; Irving (TX); On-site; USD 55,000 - 85,000; Full time

Job summary

SNI Companies in Irving, Texas seeks a Senior Claims Examiner to review, analyze, and resolve complex medical claims in line with processing guidelines and federal regulations. The role collaborates with various operational teams to ensure validation and quality assurance of claims processing.

You will analyze CMS-1500 and UB-04 submissions, handle payment resolution, refunds, and adjustments, and support system upgrades and testing for new processes.

Qualifications

• Analyze medical claim information and take appropriate action for payment resolution in accordance with policies and procedures, desktops, processing guidelines, and federal regulations.
• Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc.

Responsibilities

• Analyze medical claim information and take appropriate action for payment resolution in accordance with policies and procedures, desktops, processing guidelines, and federal regulations.
• Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc.
• Work claim projects resulting from overpayments or underpayments related to manual processing errors, benefit updates, and/or contract, fee schedule changes.
• Process provider refunds, reconsiderations, and direct member reimbursements.
• Process medical claim adjustments, recovery of claim overpayments, and execution of claim batch adjudication.
• Solve moderately complex claims and escape issues to the Claims Team Lead, Supervisor or Manager.
• Assist with database improvements and testing for system upgrades, conversions, or implementation of new processes

Skills

Medical claims analysis

CMS-1500

CMS-1450/UB-04

Regulatory compliance

Payment resolution

Tools

Claims processing software

Job description

The Senior Claims Examiner is responsible for reviewing, analyzing, researching, and resolving complex medical claims in accordance with claims processing guidelines and desktops, as well as, ensuring compliance with federal regulations. This role works in conjunction with Business Configuration, Network Management, Provider Data, Complaints, Appeals and Grievances as well as other operational departments to ensure validation and quality assurance of claims processing.

Responsibilities:

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.

• Analyze medical claim information and take appropriate action for payment resolution in accordance with policies and procedures, desktops, processing guidelines, and federal regulations.
• Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc.
• Work claim projects resulting from overpayments or underpayments related to manual processing errors, benefit updates, and/or contract, fee schedule changes.
• Process provider refunds, reconsiderations, and direct member reimbursements.
• Process medical claim adjustments, recovery of claim overpayments, and execution of claim batch adjudication.
• Solve moderately complex claims and escape issues to the Claims Team Lead, Supervisor or Manager.
• Assist with database improvements and testing for system upgrades, conversions, or implementation of new processes