[Hiring] Claims Examiner I @Florida Blue

Role Description

As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity.

The essential functions listed represent the major duties of this role; additional duties may be assigned.

• Day-to-day processing of claims for accounts:
• Responsible for processing of claims (medical, dental, vision, and mental health claims)
• Claims processing and adjudication
• Claims research where applicable
• Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic)
• Meet and/or exceed qualitative and quantitative production standards
• Investigation and overpayment administration:
• Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers
• Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records
• Utilize systems to track complaints and resolutions
• Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading

Qualifications

• 2+ years related work experience
• Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry
• High school diploma or GED
• Knowledge of CPT and ICD-9 coding required
• Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required
• Proven judgment, decision-making skills, and the ability to analyze
• Ability to learn quickly and multitask
• Proficiency in maintaining good rapport with physicians, healthcare facilities, clients, and providers
• Concise written and verbal communication skills required, including the ability to handle conflict
• Proficiency using Microsoft Windows and Word, Excel, and customized programs for medical CPT coding
• Review of multiple surgical procedures and establishment of reasonable and customary fees

Requirements

• Some college courses in related fields are a plus
• Other experience in processing all types of medical claims helpful
• Data entry and 10-key by touch/sight

Benefits

• Medical, dental, vision, life, and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Flexible schedules after training
• Leave programs to support personal circumstances
• Retirement Savings Plan includes employer contribution and employer match
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available and a comprehensive wellness program