Processor • allen tx
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Summary Of Position: Under the guidance and direction of the Team Leader (Claims Supervisor), the primary role of a Senior Claims Examiner is that of a superior claims processor with a thorough knowledge of all claims processing systems, claim processing rules and medical policy. The successful candidate will also possess analytical skills to aid in research and resolution of Adjustment inquiries and/or correspondences. The incumbent will also possess a cooperative spirit that will lead to information sharing with the goal of enhancing the overall performance of the Department.
Major Duties And Responsibilities: Proficient in the use of all claim related systems, including Claims Processing System, Claims Workflow, Claims Pricing system, Claims processing rules and Desk Level procedures. Interpret and apply applicable processing guidelines while interacting with on-line system edits/pends. Research written and/or verbal queries from providers/members/internal departments to determine appropriate action on claim and process corrections as required. Analyze patient and medical information to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly. Adjudicate all claim types, including professional and facility for all lines of business. Process voids and adjustments as required. Meet and maintain individual and departmental productivity and quality standards. Review and release high dollar claims or other complex claims adjudicated by less senior examiners as directed by the Team Leader (Claims Supervisor). Review reports and research pended claims to ensure timely adjudication within accepted corporate cycle times. Reports include, but are not limited to, daily hot and pend reports, weekly cumulative pend, and other special reports as received from customer. Identify, based on review and research of pend reports, and inform.
Job Location: USTXPAOC01 Plano - TX USA, CLT Alternate.
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