Claims Examiner I

Position Overview

The Claims Examiner I is responsible for the data entry and system adjudication of provider claims. The incumbent authorizes final disposition of claims within prescribed guidelines in an accurate and timely manner.

Scope of Role & Responsibilities:

• Process claims involving medical and/or surgical services; screens for complete member/provider information
• Apply administrative policies when necessary, utilizing the claims processing manuals
• Authorizes the generation of letters/questionnaires to providers to obtain additional information
• Reviews descriptions of services on claims to determine validity of charges of the presence of errors
• Evaluates and examines claims pended by the system due to contractual and/or payment discrepancies
• Maintains production and quality goals established for the department
• Performs other related duties, i.e., maintaining individual production counts, updating manuals and reference materials, attending all refresher training seminars

Required Education, Training & Professional Experience

• Associate’s Degree required; and
• Minimum 2 years’ experience in the healthcare insurance industry with knowledge of integrated claims processing; or
• A satisfactory equivalent combination of education, training, and experience
• Proficiency with data entry skills
• Through knowledge of medical terminology, CPT, ICD-p, and Revenue Codes

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

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