Claims HMO - Complex Claims Specialist 140-1039

JOB SUMMARY:

The Complex Claims Specialist is responsible for examining claims that require review prior to being adjudicated.  Claims are generally of the largest dollar value and require extreme attention to detail and strong knowledge of claims processing.  The examiner will use their resources, knowledge and decision-making acumen to determine the appropriate actions to pay, deny or adjust the claim. The Complex Claims Specialist will generally handle claims involving multiple lines of business and will be knowledgeable of contracts and agreements with contracted providers and facilities. 

KEY RESPONSIBILITIES:

• Examining and adjudicating claims for multiple lines of business that have pended for review utilizing resources, tools, knowledge and decision-making in determining appropriate actions
• Enter claims information using the processing software, contracts and other agreements to compute payments, allowable amounts, limitations, exclusions and denials.
• Identify and communicate trends or problems identified during adjudication process.
• Accurately resolves most unique problems or situations without supervisor involvement.
• Frequently partners internal departments and with vendors that conduct bill reviews to assist in review and pricing of claims.
• Updating reports and tracking of claims information to ensure timeliness in adjudicating claims.
• Constantly communicating with internal departments, supervisor, senior leadership and others inside the organization regarding claims, procedures, pricing and various other reasons.
• Communicates with providers to obtain records or other materials vital to adjudicating claims.
• Contribute to the creation of a pleasant working environment with peers and other departments.
• Assist in investigating and solving claims that require additional research.
• Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.
• Assist in mentoring or development of new examiners.
• Perform other duties as assigned.

QUALIFICATIONS:

• Self-motivated and able to work with minimal direction.
• Ability to read and understand claims contracts, processing manuals, medical terminology, CPT codes, and perform the most complex processing procedures.
• Ability to read and understand health benefit booklets.
• Demonstrated learning agility.
• Successful completion of Health Care Sanctions background check.
• Significant knowledge in the contracted managed care plan terms and rates for multiple lines of business.
• Demonstrated understanding of unbundling methods, COB, and other over-billing methodologies.
• Demonstrated ability to be detail-oriented.
• Proficient in Microsoft applications.
• Ability to perform basic mathematical calculations.
• Demonstrated strong oral and written communication skills.

EDUCATION/EXPERIENCE:

• High School Diploma or Equivalent required.
• Three years related work experience in claims processing, data entry or medical billing.  One year of claims processing experience within CommunityCare or another healthcare environment is required.