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Magnacare
Claims Examiner IIMagnacare • Las Vegas, NV, United States
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Claims Examiner II

Claims Examiner II

Magnacare • Las Vegas, NV, United States
5 days ago
Job type
  • Full-time
Job description

Claims Adjudication Specialist

Primary Responsibilities

  • Review and adjudicate claims submitted for reimbursement that fall outside auto adjudication standards on a daily basis, ensuring compliance with quality, productivity, and timeliness requirements.
  • Applying medical policies, contractual provisions, and operational procedures to ensure precise adjudication and adjustments.
  • Generate correspondence, such as letters and questionnaires, to gather additional information from customers and providers; may also initiate phone inquiries.
  • Collaborate with Customer Service to address and resolve customer inquiries and concerns effectively.
  • Research and resolve client inquiries and escalations in a timely manner, collaborating with internal teams as needed to ensure effective resolution.
  • Execute client-requested claim adjustments and provide clear, concise written responses to client inquiries within established deadlines.
  • Perform in-depth research on account receivables and spreadsheets that require claim adjustments, delivering thorough and clarifying responses to providers and clients.
  • Must be adaptable and willing to provide backup support across various departments and roles as needed
  • Responsible for processing all claim types including Professional and Facility claims
  • Perform Claim Adjustments as needed. Execute client-requested claim research and adjustments and provide clear, concise written responses to client inquiries within established deadlines

Essential Qualifications

  • Strong knowledge of healthcare contracts, medical terminology, and claims processing procedures.
  • Prior experience processing claims is required.
  • Minimum 1 year of experience in medical billing, claims adjudication, or a related role.
  • Excellent written and verbal communication skills, with the ability to manage inquiries professionally and efficiently.
  • Strong analytical skills with the ability to research and resolve complex claim issues.
  • Proficiency in Microsoft Office Suite, particularly Microsoft Word and Excel.
  • Ability to meet production and quality standards while managing multiple priorities.
  • Strong problem-solving skills and the ability to maintain professionalism under pressure.
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Claims Examiner II • Las Vegas, NV, United States

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