Claims Examiner

Job Specifications:

1.Graduate of a Bachelor’s Degree of any allied medical profession.

2.License is required – RN, PTRP, RPH or OD.

3.Minimum of one year Philippine or US healthcare insurance and claims experience is required

4. Ability to work on full time schedule including extended hours, weekends, and holidays.

5.Knowledge of healthcare insurance and medical terminology; Codes – ICD-9, CPT,

HCPCS; CMS/ADA Claims Forms; Medicare and NCCI guidelines’ Fee Schedules

and HIPAA are preferred.

6.Typing skills: 40 WPM for keyboard and 150 KPM for 10-key.

7.Computer literate and proficient in MS Office Applications.

8.Outstanding oral and written communication skills.

9.Strong ethics and a high level of personal and professional integrity.

10.Excellent customer service skills.

11.Effective team player and good interpersonal skills.

12.Supports organizational and departmental philosophy, objectives and goals.

13.Able to work independently and with minimal supervision.

14.Ability to prioritize and organize multiple tasks.

15.Capable of handling demands and time pressure workload.

16.Must be able to meet set deadlines and goals.

Duties and Responsibilities:

1.Production

1.1.Processes 150 claims daily based on compliance regulation and timeframes.

1.2.Assigned to process On-island, Outer-island and /or Off-island professional (CMS-1500); dental (ADA) and facility (UB-04) claims.

1.3.Processes member/reimbursement claims as assigned.

1.4.Examines claims with a payment security limit of less than $1,500.00

1.5.Process claims based upon contractual and/or TakeCare agreements, involving the use of established payment methodologies, applicable regulatory legislation, claims processing guidelines and company policies and procedures.

1.6.Reviews services for appropriateness of charges and applies authorization guidelines during claims processing.

1.7.Prepares written requests to providers; follows up and handles completion of claims for returned correspondence.

2.Quality

2.1. Analyzes, processes, researches, adjusts, and adjudicates claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e., co-payments, deductibles, etc.

2.2. Responsible for maintaining a 95-98% claims processing accuracy rate.

2.3. Meets the 30 days claims processing turn around time.

2.4. Strict compliance of all HIPAA rules and regulations.

2.5. Ensures all Protected Healthcare Information (PHI) is secured.

3.Customer Service

3.1. Assigned to service various small to mid-sized Commercial groups.

3.2. Responds to inquiries from internal departments and external customer in a timely and courteous manner.

3.3. Responds and solves issues referred by the Customer Service Dept within 2-5 working days.

3.4. Resolve provider or physician group claims inquiries and executes resolution in a timely fashion.

4.Reporting

4.1. Creates and maintains a daily production report.

4.2. Maintains a clear and precise data entry log of all created claims.

4.3. Updates the daily batch log.

4.4. Reconciles daily batch logs and reports any discrepancy to Team Lead.

4.5. Updates and prepares reports for Management Team as required.

4.6. Informs and reports to Claims Team Lead, Claims Supervisor and/or Claims Manager issues that impact production and quality.

4.7. Routinely updates milestones and goals within the performance goal system.

5.Performs other duties as assigned.