[Hiring] Specialty Claims Examiner @DELTA HEALTH SYSTEMS MCC

Role Description

• Evaluate claims and determine payment or denial according to plan provisions, medical policy, and guidelines.
• Process claim payment thoroughly, attend all training, and refresher courses.
• Maintain clear claim notes, benefit quote documentation, thoroughly review patient and family notes.
• Maintain multiple network access for pricing and authorization to avoid inactivity and disruption for processing.
• Establish and maintain COB files, determine other coverage according to regulatory and plan requirements.
• Applies COB payments for final claim payment.
• Research and determine proper CPT procedure and ICD-10 Diagnosis Codes.
• Research and respond to written correspondence from participants, providers, and local unions/employers.
• Transfer claims to Benefit Review for processing instructions and or other departments according to guidelines.
• Work effectively to achieve at a minimum production, quality, and accuracy standards.
• Display maturity, composure and ability to operate under stress conditions.
• Follow department policy and procedures distributed.
• Attend mandatory department meetings as scheduled.
• Assist other department areas as required dependent on workload and inventory needs.
• Excellent organization and assignment management skills.
• Clear communication with internal and external customers.
• Ability to navigate in external network pricing platforms.
• Ability to prioritize workload and adhere to network administrative agreements.
• Maintains professionalism at all times.
• Perform other duties as assigned.

Qualifications

• High school diploma or equivalent. Satisfactory completion of medical terminology course may substitute for six (6) months of equivalent experience.
• Eighteen (18) months experience as a Claims Processor or similar function.
• Must have a broad knowledge of medical terminology.
• Must possess excellent written and oral communication skills.
• Must possess good judgment skills and ability to interpret Department guidelines and contractual benefits.
• Working knowledge of DHPR and CMS rules for Claim Submission, Claim Payment, Eligibility, Coordination of Benefits Primary / Secondary.
• Experience with Claims and Enrollment systems; COB validation; Understanding of primary secondary coverage rules.
• Must be proficient in Excel.