Claims Examiner

Job Summary

This position properly applies plan provisions on self-funded groups. This position is responsible for claims processing of medical, dental and vision claims, and answers questions in accordance with relevant terms and established procedure. This individual works closely with other departments to proactively research concerns and resolve to the satisfaction of the client. This position maintains a comprehensive understanding of the plan document(s) under their scope of responsibility.

Duties/Responsibilities

Claims Processing

• Interprets plan documents.
• Reviews, researches, and analyzes information to determine eligibility.
• Processes, denies, pends, or allows claims.
• Uses thought and reasoning to manage workload that carries an average level of financial risk.

Correspondence

• Accurately notes the system of all information received.
• Forwards all records.

Group Contacts

• Tracks and returns calls and e-mails.
• Answers specific plan and claim questions.
• Knows each Team Member for each group.
• Goes over review issues.

Appeals and Inquiries

• Notes system when appeals and inquiries are received.
• Records all information on appeals and inquiries in the database.
• Notes system if notified that claim is going to outside review or committee.

Customer Service

• Acts as a role model in demonstrating the core values in customer service delivery.
• Provides timely and thorough follow up with, internal and external customers.
• Tracks and returns telephone calls/mail to members and groups answering specific plan/claim questions within 24 hours.
• Appropriately escalates difficult issues up the chain of command.

Quality Assurance

• Ensures team compliance with service standards.
• Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction.
• Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters.
• Performs self-quality monitoring in order to develop and execute plans to meet established goals.
• Provides ongoing feedback to help optimize quality performance.
• Collaborates with others and cross-departmentally to improve or streamline procedures.
• Remains current on industry trends and looks for new data sources.
• Develops new or improves current internal processes to improve quality.

Education and Experience

Required Education: High School Diploma or equivalent

Preferred Education: Associate degree in Medical Billing and Coding or related field

Required Experience: 1+ years' experience in clerical and customer service

Preferred Experience: Claims or Medical Office experience. Knowledge of medical terminology.

Skills and Abilities

• Working knowledge of computers and software including but not limited to Microsoft Office products.
• Proficient mathematical, 10-key and typing skills.
• Demonstrated organizational skills, problem-solving, analytical skills and detail oriented.
• Demonstrated ability to remain neutral and maintain confidentiality.
• Strong written and oral communication skills.
• Demonstrated ability to work independently, prioritize workloads multi-task and manage priorities in order to meet deadlines.

Physical Requirements

• Work is indoors in an office environment with moderate noise.
• Intermittent physical effort involving lifting of up to 25 pounds, walking, and stooping, kneeling, crouching, or crawling is required.
• A typical workday involves sitting, frequent use of a keyboard, reaching with hands and arms, and talking and hearing, approximately 70% of the time.
• Approximately 30% or less of the time is spent standing.
• Normal vision abilities required, including close vision and ability to adjust focus.

What can Imagine360 offer you?

• Multiple Health Plan Options, including a 100% Employer Paid Benefit Options.
• 100% Company paid employee premiums for Dental, Vision, STA, & LTD, plus Life Insurance.
• Parental Leave Policy.
• 20 days PTO to start / 10 Paid Holidays.
• Tuition reimbursement.
• 401k Company contribution.
• Professional development initiatives / continuous learning opportunities.
• Opportunities to participate in and support the company's diversity and inclusion initiatives.

Key skills/competency

• Claims Processing
• Medical Claims
• Dental Claims
• Vision Claims
• Plan Provisions
• Customer Service
• Medical Terminology
• Data Entry
• Problem-Solving
• Confidentiality