Claims Examiner 2-Managed Care
Summary
Processes HMO risk claims for professional and hospital services, verifies risk pool determinations, and ensures audit readiness using medical coding standards like CPT and ICD10.
Department: UHC: Managed Care
Job Summary: This Claims Examiner 2-Mgd Care will process professional and hospital HMO Risk claims in accordance with the individual provider contracts in an accurate and timely manner, verify system assigned risk pool determination in accordance with HMO Division of Financial Responsibility matrix, initiate check run, perform standard reporting, ensure audit readiness, and process third party claims. Performs other duties as needed.
Education and Experience: High School Diploma or GED required. Bachelor's Degree in Computer Science, Business, or similar degree preferred. Minimum five years managed care claims processing experience with professional claims and institutional claims.
Knowledge and Skills: Knowledge of Microsoft Office Suite. Must be well versed in medical terminology, CPT, and ICD9/10 coding guidelines. Comprehensive understanding of institutional inpatient and outpatient hospital claims processing, DRG's and all other institutional calculation standards. Comprehensive understanding of professional claims adjudication process. Understanding of the Managed Care health care delivery system. Able to use a computer, printer, and software programs necessary to the position (e.g., Word, Excel, Outlook, PowerPoint). Operate/troubleshoot basic office equipment required for the position. Able to work calmly and respond courteously when under pressure; collaborate and accept direction. Able to think critically; manage multiple assignments effectively; organize and prioritize workload; work well under pressure; problem solve; recall information with accuracy; pay close attention to detail; work independently with minimal supervision. Able to distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens, and written documents necessary to the position.
Licensures and Certifications: Certified Professional Coder preferred. Valid Driver's License at time of hire.