Description

Provides operational support for activities associated with all phases of the claims process. Ensures accurate and
timely payment of claims to meet or exceed customer service level agreements. Receive, sort, batch, scan and verify all
incoming claims. Properly adjudicate claims based on knowledge of covered benefits, insurance and provider contracts.
Identify and resolve issues around pended claims. Manage claims adjudication and case negotiation process as it relates
to moter vehicle accidents (MVA) and worker's compensation (WC) cases. Coordinate benefits (COB) with other insurers.
Determine plan liability as well as diversion and recovery activity for MVA, WC and COB claims.

Typically, the Representative provides second level support of claims operations. Acts as point of contact for
customers and internal departments in answering questions regarding complex or non-routine claims. Interacts on a daily
basis with other insurance carriers, lawyers and the legal department. Investigates and determines claim liability.

Requirements

You must have a strong working knowledge of all aspects of medical claims adjudication including medical protocol &
diagnostic billing standards (CPT & ICD-9 coding) utilizing multiple PPO networks.
We’re looking for an organized, detail-oriented, professional who thrives in a productivity & quality conscious
environment.
You must be pc/Windows literate and possess a working knowledge of MS Office (Outlook, Excel & Word)
Minimum 6 months experience as a medical claims examiner.