[Hiring] Medicaid Claims Examiner II @HealthEdge

Role Description

HealthEdge is looking for Claims Examiner II, reporting to the Claims Team Leader. The Claims Examiner II is responsible for the adjudication of healthcare claims utilizing specific policies and procedures. This role is responsible for reviewing data within the claims processing system, to determine if services rendered were appropriate and benefit coverage criteria were met. The Claims Examiner II is accountable for reviewing the adjudication system edits to determine whether to pay the claim and/or line item(s).

• Be responsible for processing assigned claims based on client-specified guidelines or as directed by the team leader.
• Be responsible for meeting productivity targets, financial and procedural accuracy standards as established by management.
• Mentor junior members of the team.
• Collaborate with other team members on special projects as assigned by the team leads; special projects can include:
  • Process documentation development
  • Training
  • Quality audits
  • Assisting with surge activity for the client(s)
  • Any other project as determined by the team leader
• Knowledge base around physician practices and hospital coding, billing and medical terminology, CPT, HCPCS, and ICD-10, UB04, CMS 1500, authorizations, medical terminology, and concepts of healthcare.
• Establish and maintain an appropriate level of communication with management to address issues and concerns and take preventive measures that ensure processing accuracy and quality.
• Participate in projects assigned by the team leader; these projects may include provider data, authorizations, enrollment, or other activities.

Qualifications

• High School degree required
• 1 – 3 years healthcare claims processing experience
• Solid understanding and ability to analyse claim data
• ICD-10 CPT and HCPCS coding, is a plus
• Willingness to learn new skills
• Team collaborator
• Strong work ethic

Requirements

• The ability to adapt quickly to a fast-paced environment
• A self-starter and quick learner
• Team player with an ability to collaborate

Work Environment

• The employee is occasionally required to move around the office.
• Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
• Work across multiple time zones in a hybrid or remote work environment.
• Long periods of time sitting and/or standing in front of a computer using video technology.
• May require travel dependent on company needs.