The Claims Examiner properly applies plan/guidelines provisions. This position is responsible for processing medical, dental and vision claims, and answers questions in accordance with relevant terms and established procedure. This position works closely with other departments to proactively research concerns and resolve to the satisfaction of the client. This position will handle complex claims issues, assist with team workflow management and any special projects as assigned. This position maintains a comprehensive understanding of the plan document(s)/guidelines under their scope of responsibility.

Essential Job Duties:

• Maintain HIPAA/PII guidelines to ensure the confidentiality of all calls and documents
• Claims Processing
• Interpret plan documents/guidelines
• Determine eligibility by reviewing, researching and analyzing information
• Process, deny, allow or pend claims
• Manage a moderate volume and complexity of groups and members
• Use critical thinking and reasoning to manage workload with above average level of financial risk
• Provide training to new and assigned employees
• Correspondence
• Maintain and enter information into system as information is received
• Forward all records to the appropriate parties
• Group Contacts
• Record and respond to calls/e-mails from Groups
• Maintain high level of knowledge to answer specific plan/guideline and claim questions
• Establish relationships with Team Members for each group
• Review issues as they arise
• Appeals and Inquiries
• Note system when appeals and inquiries are established 
• Record all information on appeals and inquiries in the database
• Note in system if claim is going to a committee or to outside review
• Customer Service
• Serve as a role model in demonstrating core values of customer service
• Provide timely and thorough responses to internal and external customers
• Respond to member and group correspondences regarding plan/guideline or claim questions within 24 hours
• Escalate difficult issues to the appropriate chain of command
• Quality Assurance
• Ensure compliance with service standards
• Follow trends within assigned scope and alert appropriate parties of any that fall outside quality parameters
• Develop and execute plans to meet established goals 
• Provide continuous feedback to strengthen and optimize quality performance
• Work cross-departmentally to improve or streamline procedures
• Maintain up to date knowledge on industry trends and look for new data sources
• Develop or improve current internal processes to improve overall quality 
• Special projects as assigned

Skills/Abilities:

• Excellent verbal and written communication skills with high attention to detail
• Excellent customer service skills 
• Strong analytical and problem-solving skills
• Confident decision-making abilities
• Demonstrated ability to work independently, prioritize workloads and manage priorities to meet deadlines

Education/Experience:

• High school diploma or equivalent required
• Associates degree in Medical Billing and Coding or related field preferred
• 2 -5 years of Claims Examiner experience or equivalent required
•  Javelina a huge plus 
• Knowledge of medical terminology preferred

Physical Requirements:

• Indoor office environment with moderate noise
• Intermittent physical effort may include lifting up to 25 lbs., walking, stopping, kneeling, crouching or crawling may be required
• Frequent sitting, use of a keyboard, reaching with hands and arms, talking and hearing approximately 70% of the time; 30% or less time is spent standing
• Normal vision abilities required including close vision and ability to adjust focus