Claims Examiner - #1412758

Purpose of the Job

The Claims Examiner is responsible for providing claims production to the Claims Production Team to enable the administration of non-auto adjudicated claims which contributes to the overall success of Claims Production ensuring specific individual goals, plans, initiatives are executed and delivered in support of the team’s business strategies and objectives. The Claims Examiner is responsible for maintaining and adhering to internal controls, ensuring compliance with applicable laws and regulations, and following Health New England’s entity level policies and procedures. The position is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England’s Code of Conduct.

Accountabilities

• Champions a customer focused culture to deepen client relationships and leverage broader Health New England’s relationships, systems and knowledge.
• Understand how Health New England’s culture and the CX Promise should be considered in day-to-day activities and decisions.
• Actively pursues effective and efficient operations of their respective areas in accordance with Health New England’s Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct.
• Champions a high-performance environment and contributes to an inclusive work environment.
• Contributes to overall Claims Production productivity by accurately adjudicating claims at all levels of complexity.
• Meets/exceeds individual, role, and departmental standards of quality and productivity.
• Finalizes claims to correct processing discrepancies and other edits by reviewing all available information and applying documented policies and procedures.
• Resolves specialty pends to remedy processing discrepancies and other edits while coordinating editing from external Claims Adjudication Partners/vendors.
• Evaluates claims to ensure payments are reasonable for the services rendered.
• Identifies discrepancies and/or gaps in auto adjudication, documented policies and procedures to Senior Examiners.
• Identifies unexplained variations in claims adjudication to Senior Examiners.
  
  

Education / Experience / Other Information

High School diploma with a minimum of 3 years of progressively responsible health care claims insurance administration experience or an equivalent combination of education and experience.

• Knowledge and understanding of health care payer industry standards; Experienced in healthcare related standards such as HIPAA, ACA, CMS, AMA, DOI, MassHealth, ERISA and other regulatory agencies
• Healthcare knowledge of industry coding standards/forms including by not limited to CPT4, ICD10, UB04, and HCF1500.
• Experience with health claims processing systems and related technology.
• Experience in handling confidential information.
• Excellent interpersonal skills; Demonstrated ability to work with teams.
• Excellent oral and written communication and interpersonal skills.
• Proficiency with Microsoft Office products.
  
  

Working Conditions

• Work in a standard office-based environment; non-standard hours are a common occurrence. Limited travel.