Here's what you'll be doing:
Level II - Level III
1 - Analyzes and processes minimum of 200 claims daily to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims
2 - Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations
3 - Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments
4 - Assists with other research and development projects as directed by Management; obtains and maintains necessary certification for Health Insurance Marketplace CAC
5 - Provides training and guidance through expert knowledge of claims administration and adjudication to Insurance Department staff; responsible for the timely response to formal appeals from members, employees, clients and providers
6 - Reviews, resolves and/or escalates Level 2 claims appeals; releases claims up to the designated draft authority for Level 2 Claims Examiner
7 - Works with the Customer Service Coordinator to manage and provide direction to the utilization review and case management vendor; identifies and manages claims with potential subrogated recovery
8 - Ensures that claims adjudication complies with all FCPID standards and protocols; reviews claims for possible abuses and/or fraud and bring to the attention of management
9 - Oversees the repricing processes to ensure the integrity of the product; investigates claims referred by staff for possible abuse and fraud
What you'll need to be successful:
Level II - Level III
1 - High School Diploma or GED
2 - Five (5) years of experience in medical claims processing
3 - Three (3) years in customer service
4 - Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards
5 - Two (2) years in a lead or supervisory capacity
6 - Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology
7 - Knowledge of insurance principles and/or procedures
8 - Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment
9 - Must successfully pass all applicable background checks and drug screens
Benefits you'll love:
Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
Insurance Claims Examiner II • Crandon, WI, United States
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