Resp & Qualifications
The Claims Examiner is responsible for the accurate and timely processing of claims per regulatory and contractual guidelines.
Essential Duties and Responsibilities
- Responsible for accurate and timely adjudication of claims according to guidelines.
- Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-10 codes, under the correct provider and member benefits, i.e. co-payments, deductibles, etc.
- Claims processing based upon contractual agreements, involving the use of established payment methodologies.
- Alerts manager or supervisor of issues that impact production and quality, i.e. incorrect database configurations, non-compliant claims, etc.
- Process claims based on compliance regulation and timeframes.
- Process both professional (CMS-1500) and facility (UB-04) claim types.
- Maintain quality and productivity standards as set by management.
- Review services for appropriateness of charges and apply authorization guidelines during claims processing.
- Other duties as assigned by management.
Education, Experience and Qualifications
- High School graduate or equivalent.
- 2-3 years’ experience processing on-line claims in a managed care and/or PPO/indemnity environment.
- Experience processing Medicare or Medicaid claims preferred.
- Customer service and organizational skills required.
- Experience with HealthRules Payor preferred.
Knowledge, Skills and Abilities
- Revenue Codes, CPT-4/HCPCS, ICD-10 codes.
- Industry pricing methodologies, such as RBRVS, Fee Schedule, DRG, etc.
- Medical terminology.
- Benefit interpretation and administration.
- Microsoft Office including Share Point, Outlook, Excel and Word
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 8/11/21
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship