Medical Claims Examiner - Onsite - EDI Staffing
Coral Gables, FL 33134
About the Job
Our client has an exciting opportunity for a Claims Examiner to join their growing Claims Department. This is an onsite position based in Coral Gables, FL.
The Claims Examiner is responsible for the accurate and timely processing of healthcare claims, ensuring compliance with departmental procedures and industry standards. This role requires a deep understanding of hospital and physician billing, including Medicare, Medicaid, and Commercial claims processing. The ideal candidate will possess expertise in ICD-9 and ICD-10 coding, policy interpretation, and the use of CPT codes, hospital coding, and UB-04 forms. The Claims Examiner will be tasked with ensuring the quality and accuracy of processed claims, identifying cases for audit, and managing appeals and balance billing cases from start to resolution. The role also involves working with Medicare Advantage and capitation plans, contributing to risk assessment processes, and maintaining strong communication with clients and providers.
Duties & Responsibilities:
The Claims Examiner is responsible for the accurate and timely processing of healthcare claims, ensuring compliance with departmental procedures and industry standards. This role requires a deep understanding of hospital and physician billing, including Medicare, Medicaid, and Commercial claims processing. The ideal candidate will possess expertise in ICD-9 and ICD-10 coding, policy interpretation, and the use of CPT codes, hospital coding, and UB-04 forms. The Claims Examiner will be tasked with ensuring the quality and accuracy of processed claims, identifying cases for audit, and managing appeals and balance billing cases from start to resolution. The role also involves working with Medicare Advantage and capitation plans, contributing to risk assessment processes, and maintaining strong communication with clients and providers.
Duties & Responsibilities:
- Process and examine all incoming claims based on departmental procedures.
- Understand hospital and physician billing and collections, including Medicare A & B, Medicaid, Commercial and PPO claims processing.
- Interpret, apply, and comprehend policy terms, deductibles, coinsurance, copays and policy max
- Code ICD-9 and ICD-10 while utilizing expertise in claims processing, policy interpretation, CPT codes, hospital coding, UB-04 forms, and Correct Coding Initiative (CCI) principles.
- Meet clients' claims processing deadlines.
- Review and perform quality assessments of work being released to clients to ensure claims processing errors are kept at a minimum.
- Identify claims that should be audited by the Medical Team
- Follow up on network pending claims.
- Receive and register appeals/balance billing cases into the system and distribute according to department procedure.
- Review and determine, according to department procedure, how to resolve the appeal/balance billing.
- Provide continuous updates to both clients and providers until appeal/balance billing case is closed.
- Handle Provider Statements and invoices by contacting the providers to request a completed claim form.
- Work with Medicare Advantage plans, capitation plans, risk assessment process and payments.
- Performs other similar and related duties.
Required Experiences:
- Experience in healthcare claims processing, billing, and coding within a hospital or physician practice setting.
- Proven expertise in ICD-9 coding, ICD-10 preferred, with a strong understanding of CPT codes, UB-04 forms, and Correct Coding Initiative (CCI) principles.
- Extensive knowledge of Medicare A & B, Medicaid, Commercial, and PPO claims processing.
- Experience in interpreting and applying policy terms, deductibles, coinsurance, copays, and policy maximums.
- Background in managing appeals and balance billing cases, with demonstrated ability to resolve complex billing issues.
- Experience with Medicare Advantage plans, capitation plans, and risk assessment processes.
- Strong analytical skills with the ability to review, assess, and improve claims processing accuracy and efficiency.
- Attention to detail to ensure compliance with regulatory requirements and minimize errors.
- Excellent communication skills for effectively interacting with clients, providers, and internal teams.
- Proficiency in using claims processing software and related tools.
- Ability to work under pressure and meet tight deadlines in a fast-paced environment.
- Strong organizational skills with the ability to manage multiple tasks and priorities simultaneously.
- Problem-solving skills to identify and resolve issues related to claims, coding, and billing.
- Knowledge of regulatory guidelines related to Medicare, Medicaid, and commercial insurance plans.
- Excellent health and dental insurance coverage
- Free vision, life and hospital gap insurance
- 12 paid holidays
- Paid Time Off
- 401K with company match up to 4%
- Salary range is commensurate with the experience of the candidate
Source : EDI Staffing
