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MetroPlusHealth
Claims Examiner IMetroPlusHealth • 50 Water Street, 7th Floor, New York, NY
Claims Examiner I

Claims Examiner I

MetroPlusHealth • 50 Water Street, 7th Floor, New York, NY
30+ days ago
Job type
  • Full-time
Job description

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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Claims Examiner I • 50 Water Street, 7th Floor, New York, NY

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