Claims Examiner in Meridian, ID at APEX Systems

Date Posted: 10/21/2019

Job Snapshot

  • Employee Type:
    Contractor
  • Location:
    Meridian, ID
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    10/21/2019

Job Description

Job #:  1001167


POSITION PURPOSE:
Under immediate supervision, assure the timely and accurate processing of claims business for all contracts within corporate standards, as well as meet any performance guarantees that Administrative Service Contract (ASC) accounts have indicated in their Administrative agreements. 
MINIMUM POSITION REQUIREMENTS:
Required Experience:
  • Six months claims or customer service related work experience in the health insurance
    industry; or
  • 18 months work experience in a general office or medical office environment

Required Knowledge, Skills and Abilities (KSAs):
Knowledge of:
  • Medical Terminology
  • Excel

Skills:
  • Outlook – Basic
  • Word – Basic
  • Typing – 35 wpm
  • Ten-key – 75 kspm
  • Math – Basic
  • Organizational
  • Time Management
  • Verbal & Written Communication
  • Problem Solving

Ability to:
  • Complete assigned individual tasks within scope
  • Research and navigate web-based programs
  • Work with detailed-oriented material
  • Work overtime periodically as needed
  • Follow detailed workflow and instructions

PREFERRED QUALIFICATIONS:
  • Knowledge of master contracts
  • Knowledge of provider and ancillary pricing
  • Knowledge of Facets systems
  • Health claims processing (such as Medicare, Medicaid)
  • Knowledge of coding/CPC
  • SharePoint

PRIMARY ACCOUNTABILITIES: 
  1. Consistently ensure timely and accurate acceptance of claims through the review of claim history and edit or ITS reports, including the simple manual computation of benefits, both in- and out-of-network, by entering data using available resource materials such as contracts, contract benefit files, etc... Forward any claims requiring further review to the appropriate person or area according to established workflows. Process within the Facets system following the interpretation of claim information from the Host Plan transmitted through the Inter-Plan Teleprocessing System (ITS) system then through Line Item Link (LIL) and processed in conjunction with Host Plan rules transmitted through the ITS.
  2. Submit informational messages and general inquiries through BlueSquared to maintain a positive and effective working relationship with other Plans for accurate and timely claim processing. Understanding of Notification Formats (NFs). Demonstrate basic proficiency with the Facets system, and ITS systems and interpretation skills of the benefits information transmitted by the Host Plan.
  3. Recognize and report immediately any abnormal or aberrant claim practices or system configuration issues, to the Supervisor or Senior Claim Examiner for review.
  4. Recognize incorrectly processed claims in the member’s history, watching for cascade errors on all previously processed claims and notifying the appropriate personnel on a timely basis.
  5. Analyze the reasons for the edits of the claims data, and take the appropriate action needed to correct the claims, including directing claims to Medical Management, Pharmacy Management and or Behavioral Health management.
  6. Record and submit accurate work hours and time exceptions in designated applications or operating systems. Monitor individual quality and efficiency daily using online tools.
  7. Maintain in current and accessible manner procedure manuals, contracts, memos, bulletins, and all information related to benefit administration.  Access online manuals and memos on the Intranet and BlueWeb.
  8. Gain knowledge and understanding of the Policies and Standards, and Other party Liability (OPL) in the ITS environment, NFs.  Gain knowledge of the  Manuals, ITS systems, ITS Data Format and Plan Profiles. 

SECONDARY ACCOUNTABILITIES:
  1. Participate in area quality review of other employees in department to assist with identifying training needs of other staff.
  2. Operate necessary office equipment such as PC, ten-key, fax and copy machine.
  3. Perform other duties as requested by the Supervisor.

 
 
 
 
 
 
 
 
 
EEO Employer
Apex Systems is an equal opportunity employer. We do not discriminate or allow discrimination on the basis of race, color, religion, creed, sex (including pregnancy, childbirth, breastfeeding, or related medical conditions), age, sexual orientation, gender identity, national origin, ancestry, citizenship, genetic information, registered domestic partner status, marital status, disability, status as a crime victim, protected veteran status, political affiliation, union membership, or any other characteristic protected by law. Apex will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law. If you have visited our website in search of information on employment opportunities or to apply for a position, and you require an accommodation in using our website for a search or application, please contact our Employee Services Department at 844-463-6178-6178.