Examiner, Claims

JOB DESCRIPTION Job Summary Provides support for claims examination activities including evaluation of adjudication of claims to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors. Essential Job Duties Evaluates the adjudication of claims using standard principles, and state-specific regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and claims processing errors. • Manages a caseload of claims - procures all medical records and statements that support the claim. • Makes recommendations for further investigation and/or resolution of claims. • Reduces defects through proactive identification of error issues as it relates to pre-payment of claims through adjudication/trend identification, and recommends solutions to resolve issues. • Meets claims department quality and production standards. • Supports claims department initiatives to improve overall claims function efficiency. • Completes basic claims projects as assigned. Required Qualifications At least 1 year of experience in a clerical role in a claims, and/or customer service setting - preferably in managed care, or equivalent combination of relevant education and experience. • Data entry and research skills. Organizational skills and attention to detail. • Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. • Customer service experience. • Effective verbal and