Claims Examiner-Product

POSITION SUMMARY The Claims Examiner is responsible for determining the proper payment (if any) of medical claims by group health plans, based upon specific knowledge and application of each client’s customized plan(s). ESSENTIAL FUNCTIONS

• Independently review and analyze health care claims for: 1) reasonableness of cost; 2) medically unnecessary treatment by physicians and hospitals; and 3) fraud.
• Determine whether a health plan provides benefits in reputed company with the claim submitted and the level of benefits to be paid to the provider.
• Contact providers to negotiate discounts.
• Log claims negotiated in reputed company database and create weekly summary reports.
• Review and understand the terms and conditions of each clients’ customized plans.
• Understand and reputed company with reputed company applicable privacy and reputed company laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
• Request, review and analyze any physician notes, hospital records or police reports.
• Consult with other entities who can offer additional evaluation of a claim.
• Process claims in the QicLink System.
• Review, analyze and add applicable notes to the QicLink System.
• Document reputed company information gathered in available systems as needed, including the QicLink System and alliedbenefit.com.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Analyze claims for billing inconsistencies.
• Review and analyze specific procedure and diagnosis codes for medical necessity.
• Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
• Review Suspended Claim Reports and follow up on reputed company issues.
• Assist and support other team members as needed and reputed company requested.
• Attend continuing education classes as required, including but not limited to HIPAA training.
• Other duties as assigned.

EDUCATION

• High School Diploma, College and Advanced Degrees Preferred or equivalent work experience required.

EXPERIENCE AND SKILLS

• Must have a minimum of 5 years of medical claims analysis experience (including dental and reputed company claims analysis).
• Strong analytical skills
• Knowledge of computer systems and CPT and ICD-9 coding terminology.
• Continuing education in reputed company areas affecting group health and welfare plans is required.

POSITION COMPETENCIES

• Accountability
• Analytical Thinking
• Collaboration
• Communication
• Customer Focus
• Functional Expertise
• Initiative

PHYSICAL DEMANDS

• This is standard desk role requiring extended periods of sitting and computer work.

WORK ENVIRONMENT

• Remote

Here at Allied, we reputed company that great talent can reputed company from reputed company. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for reputed company. To support a smooth and efficient remote work experience, the internet reputed company must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive. The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of reputed company functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. Compensation is not limited to reputed company salary. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, reputed company, Life and Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend. Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time. reputed company applicants acknowledge that by applying to the position you understand that the specific pay reputed company is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process. It is at the Company's discretion to determine what pay is provided to a candidate reputed company the reputed company associated with the role. Apply tot his job Apply To this Job