Claims Examiner Lead
Job Description Summary
The position reports to Supervisor of Claims and assists with the daily operations of the claims examiners and the clerical support staff. This position assists in the planning, directing, evaluation of workflows, coordinates work activities to achieve expected production goals, recognizes and recommends process improvements, and supports the Claims Department in reporting, training, mentoring and assigned project work.
- High school education or equivalent and minimum of five years of experience as a health claims examiner for various services that include Medical, Dental, and Vision services.
- Expert knowledge of medical claims processing in Health Maintenance Organization (HMO), Preferred Provider Organization(PPO), Exclusive Provider Organization (EPO), Point of Service (POS), Consolidated Omnibus Budget Reconciliation Act (COBRA), Long Term Care, Life Insurance Plan, Reinsurance (Stop Loss Carriers), Risk Based Models, Flexible Spending Account (FSA), Health Risk Assessment (HRA), Medicaid, Medicare, and State/Federal payers and experience with both fully insured and self-insured benefit plans.
- Expert knowledge of Electronic Data Interchange (EDI) standardization, medical terminology, claims and billing (ANSI 5010 X12 837 format) information between providers, vendors and payers.
- Excellent written and verbal communication skills – demonstrated effective and professional communication to both internal and external customers.
- Demonstrated ability to work collaboratively in a team environment, facilitate meetings, conduct training sessions, and support team decisions.
- Strong skills in multi-tasking, research, resolving processing and system issues, claim inventory, escalations, phone calls, and prioritization.
- Knowledge and understanding of Health insurance business, continuity of care and patient services flow between facilities/providers, health products, ancillary products, claim work queue operations, summary of Plan Description and Summary of Benefits/Coverage, National Correct Coding Initiative editing, National & Local Coverage Determinations from Centers for Medicare/ Medicaid Services (CMS), Health Insurance Portability and Accountability Act (HIPAA), Multiple Employer Welfare Act (MEWA), Perspective Payment Systems reimbursement system, and Employee Retirement Income Security Act (ERISA) regulations/compliance.
- Proficient knowledge of word processing, data analysis, and spreadsheet office software.
Duties And Responsibilities
- Examine large dollar claim files and adjustments and follow large dollar claim process: prepare audit package for Senior Management review and approval; coordinate with matrix partners to obtain necessary verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation. Process claims adjustments, re-pricing and corrections, and resolve pended claims within ERISA guidelines.
- Examine claims for WGAT employees.
- Examine and process professional, dental, vision claims including physician claims, Medicaid reclamation, FSA, Blue Card/Jointly Administered Agreement (JAA MCS products), foreign claims, other re-pricing claims, emergency room, outpatient lab and x-ray, accident and Third Party Liability (TPL) claims, Medicare Secondary Payer (MSP) and surgery claims.
- Resolve benefit, accumulator and eligibility issues that require detailed knowledge, support for customers and examination within the claims processing guidelines.
- Research and complete all correspondence related to all electronic and paper claims assigned.
- Reconcile and check posting for JAA accounts.
- Review and process Mental Health / Chemical Dependency claims to insure MHPAEA compliance and complex DME claims and work with Outside Vendor for Non-Par pricing.
Training and Mentorship
- Provide Subject Matter Expert (SME) support for New Hire Training, individual support training and up-training classes. Provide assistance to existing staff for claims questions.
- Provide support to the training department by preparing recommendations for “New” Hire, individual and up-training curriculum.
- Confer with management to assess training needs in response to changes in policies, procedures, regulations, and technologies.
- Participate in claims staff performance improvement plans by providing additional auditing and/or coaching as needed.
- Develop a culture of real, personal accountability by modeling the behavior that defines it.
- Participate in developing and leading a team of 3A+ self-accountable professionals.
- Serve as a resource for the examiners on complex claims topics.
- Participate in team meetings and one-one conversations along with the Claims Supervisor.
Claims Department Support
- Perform claim project work as assigned by Claims Supervisor including but not limited to Blue Card/JAA MCS reporting, FSA work, accumulations review, adjustment files and other specialties.
- Perform routine and ad hoc claims reporting as needed. Assist Account Managers with Client requests.
- Identify and escalate issues related to instructional and procedure material that is inaccurate, unclear or contains gaps. Provide recommendations for correction of this material.
- Participate in departmental error logs analytics and include the findings in training preparations.
- Participate in monitoring and improving turn-around-time, EDI efficiencies, performance guarantees, quality and production.
- Participate in distributing, evaluating and prioritizing claims inventory (paper, EDI queue claims, adjustments).
- Perform auditing of selected claims prior to nightly payment run.
- Perform special project audits and reviews as requested by other departments/regions.
- Provide support on client inquires and other operation department claims questions.
- Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results
- All other duties as assigned
Physical Demands/Work Environment
The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.