- Claims Adjudicator Examiner, MercyCare Insurance, Days, 80 Hrs/ 2 wks
- Location: MercyCare Building; Janesville, WI
Analyzes claims to determine extent of insurance carrier's liability in accordance with policy provisions regarding third party liabilities. Training of adjudicators and processors as assigned by manager. Respond to questions from adjudicators and processors. Create Standard Operating Procedures for new products as assigned by management. Review and update existing Standard Operating Procedures on a yearly basis or as needed upon upgrades to the claims payment system. Assist adjudicators and/or processors as needed in order to assure claims are completed within standards. Performs other duties as assigned.
Responsibilities
- Investigate all non-standard claim problems (25%)
- Investigates for COB and determine the primary payer (25%)
- Investigate and process adjustment requests (25%)
- Adjust claim payments resulting from duplicate payments, incorrect payee, etc.
- Recover expended funds for managed care plans
- System documentation of investigation results
- Training of Coordination of Benefits claim processing for new claims examiners
- Respond to questions from claim processors and examiners
- Training of processors and examiners as assigned by department coordinator
- Enter and process paper COB claims based on alpha split
- Investigate claims for possible third party liability through independent investigation and our legal department. This is achieved through review of claims history and medical records. May also involve direct telephone contact or written correspondence with doctors, lawyers, members or others involved to resolve coverage questions.
- Investigate non participating provider claims to determine if a discount can be obtained.
- Must understand all system edits and resolve correctly
- Assist other partners by continuously training, education or whatever means necessary to assure compliance with regulatory requirements and internal standards.
- Yearly review of standard operating procedures to assure compliance with regulatory requirements, contracts and internal standards.
- Create new standard operation procedures for new products or procedures.
- May be asked to audit partners for accuracy in entry and adjudication.
- May be asked to lead group in process improvement plans based on member complaints or audit results.
- May be asked to assist in claims data entry of claims other than those COB claims directly assigned based on alpha split.
Education and Experience
Associate degree in a health or business field or at least 5 years of experience in claims adjudication required.
Medical terminology helpful, but not required.
Extensive knowledge of Coordination of Benefits rules required.
ICD-10 and CPT-4 knowledge required.
Certification/Licensure
CEBS designation helpful, but not required.
Special Physical Demands
The Special Physical Demands are considered Essential Job Function of the position with or without accommodations.
While performing the duties of this Job, the employee is regularly required to sit, see and hear. The employee is occasionally required to stand; walk; reach with hands and arms and kneel or crouch. The employee must occasionally lift and/or move up to 50 pounds.
Culture of Excellence Behavior Expectations