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Claims Examiner
Chicago, IL

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Posted 1/06/2017

Required Skills

  • Medicare Part A experience
  • Medicare Part B experience
  • Medicare Part D experience
  • Medicare pricing

Job Description

  • Serve as the internal claims payment expert, and as a liaison between the plan, claims, providers and various departments to effectively identify and resolve claims issues
  • Review claims for medical necessity, coding and assure payment per the terms of the contract, member benefits and authorization
  • Research and resolve complex verbal and written providers’ claims inquiries
  • Provide technical review of claims and medical records including records submitted by providers and internal records provided in electronic healthcare data bases
  • Identify providers experiencing a large number of claims issues or with the potential to develop claims issues and proactively work to eliminate barriers for accurate and timely claims processing
  • Prepare both internal and external documentation, assuring clarity in communication to all stakeholders
  • Apply knowledge of medical bill analysis relating to state and federal regulations affecting medical billing practice
  • Review claims to identify any potential third party or workers’ compensation liability and inform management
  • Communicate with appropriate internal staff when identifying questionable billing practices or third party collection opportunities
  • Answer member calls related to Medicare claims payments or Medicare questions
  • Bilingual English / Spanish preferred

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