Healthcare + Heroes

Position Overview:

The Claims Examiner will be handling facility, ancillary, and provider claims based on medical authorization and apply all applicable coding edits, contractual agreements, and Plan provisions, as well as claims requiring greater confidentiality. Provide back-up support to Member Services, fielding incoming telephone calls from members and providers as needed upon request of Claims Department Director. Train and advise other claims adjusters, serve as workflow coordinator for the Claims Department as needed, and perform various system-related tasks including data transmission.

Essential Job Functions:

• Process paper (manual) and electronic professional, facility, ancillary, and provider claim submissions as appropriate (pay, deny, pend).
• Process paper (manual) and electronic professional, facility, ancillary VIP claims that require greater confidentiality.
• Research, resolve, and process adjustment claims (active or re-opened) that are more difficult, complex or escalated claims.
• Process out of network claims requiring negotiation by E-Plan vendor.
• Train and advise other claim adjusters as requested by Claims Director.
• Serve as workflow coordinator for the Claims Department in the absence of the Senior Claims Manager.
• Review all claims for potential fraud, waste and abuse, hospital acquired conditions and events.
• Identify claims with Workers’ Compensation or Third Party Liability potential and refer to appropriate area for further investigation.
• Identify claims requiring clinical review, obtain appropriate medical records, and refer to Case Management for review.
• Interface with providers; periodically follow-up on pended claims; completion of error corrections; and adjustment of claims as necessary.
• Function as a member services representative when necessary as requested by Senior Claims Manager.
• Consistently meet established productivity, schedule adherence, and quality standards.
• Other duties as assigned by the Senior Claims Manager.

Required Knowledge/Skills/Abilities/Experience:

• Minimum of 5 years recent experience required.
• 5 years desired as a health claims examiner processing Group Medical claims or equivalent education/experience such as healthcare benefits, benefit administration or health care delivery from either a payer or provider perspective.
• Expert knowledge of medical terminology, facility and physician billing practices, and CPT, ICD-9/ICD-10, HCPCS, DRG and Revenue code coding methodologies.
• Expert knowledge of the Plan in terms of covered expenses and exclusions, coordination of benefits and third-party liability provisions.
• Strong decision making, research and analytical abilities.
• Excellent typing and 10-key skills.
• Ability to work under pressure and adapt to changing environments.
• Familiarity with computer and Windows PC applications; ability to learn new and complex computer system applications, and to navigate between various computer applications/systems to conduct research and to respond to members and providers.
• Ability to communicate clearly and professionally, both verbally and in writing.
• Solid organizational skills with strong attention to detail and listening skills.
• Possess a strong work ethic and team player mentality.

Covid-19 Hiring Update: We’ve transitioned to a work-from-home model and we’re continuing to interview and hire during this time. This role is expected to begin as a remote position and will transition to a full-time office position. We will work with you to explore possible interim options. 

Our business is fast-paced and will continue to evolve. As such, the duties and responsibilities of this role may be changed as directed by the Company at any time to promote and support our business needs. 

SureCo is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, national origin, protected veteran status, or any other basis protected by applicable law and will not be discriminated against on the basis of disability.