SHSMD Career Center

Purpose Statement / Position Summary

The Claims Examiner II accurately reviews, researches and analyzes professional, ancillary and institutional inpatient and outpatient claims.

Essential Functions and Responsibilities of the Job

• Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines.
• Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims.
• Comprehensive knowledge of various fee schedules and CMS pricers for outpatient/inpatient institutional, ancillary and professional claims, including, but not limited to Medicare fee schedules, DRG, APC, ASC, SNF-RUG. 
• Ability to identify and report processing inaccuracies that are related to system configuration.
• Process all types of claims, such as, HCFA 1500, outpatient/inpatient UB92, high dollar claims, COB and DRG claim
• Reviews. processes and adjudicate claims for payment accuracy or denial of payment according to Department’s policy and procedures.
• Processes all claims accurately conforming to quality and production standards and specifications in a timely manner.
• Documents resolution of claims to support claim payment and/or decision. 
• Makes benefit determinations and calculations of type and level of benefits based on established criteria and provider contracts. 
• Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.
• Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines.
• Adjudication of Commercial and Medicare Advantage claims.
• Ability to prioritize, multitask and manage claims assignment within department goals and regulatory compliance and with minimal supervision.
• Ability to make phone calls to Provider/Billing offices when necessary based on department guidelines.
• Requests additional information or follow up with provider for incomplete or unclean claims.
• Ability to effectively communicate with External and Internal teams to resolve claims issues.
• Ability to interact in a positive and constructive manner.