Claims Examiner III

JOB SUMMARY: Is responsible for adjudicating complex claims which include high dollar claims. Responsible for accurate manual/auto pricing of claims. Identify provider billing issues that impact claims processing. Works closely with the Supervisor to identify any reporting or training needs and system problems that may be encountered. Maintains quality and production standards, teamwork and comply with company/administrative policies and guidelines.ESSENTIAL JOB FUNCTIONS:Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e. co-payment, deductible, etc.Review and process facility (UB-04) and professional claims (CMS-1500).Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups’ and company policies and procedures.Process Medicare member claims based on DMHC and DHS regulatory legislature.Respond to and resolve provider and health plan claims inquiries and give resolution in a timely manner.Review services for appropriateness of charges and apply authorization guidelines during claims processing.Monitor and track age, pended, and open reports to maintain timeliness in claims processing based on individual work allocation report.Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines.Ensures compliance with all applicable Federal, State and/or County laws and regulations related to our documented guidelines and processes.Adheres to payroll policies and properly uses timekeeping system with minimal manual changes.Maintains regular and consistent attendance.Adheres to Compliance Plan and HIPAA regulations.

MARGINAL JOB FUNCTIONS:Takes on special projects as needed.Performs other duties as assigned.