Claims Examiner
- Accesses systems and keys claim data and other information and notations from work queues. Suspends, routes and adjudicates claims and performs research as required. Also, inputs fee filing data, as required
- Creates and processes claims for pre-treatment estimates with payments.
- Maintains and updates subscribers files with information obtained through inquiries and submitted claims and documents, i.e., family on hold codes applied or removed, student status deferred, addresses updated. Reports file discrepancies to management.
- Responsible for researching and retrieving all documentation and resolving all claims in question, including student documentation, provider research, some coordination of benefits, diagnostics materials, etc.
- Understands rejects and applies appropriate RFS codes as well as processing policies on applicable claims.
- Requests information from providers and subscribers through telephone contact or written correspondence.
- Resolves claims related system generated error and adjustment reports.
- Supports and participates in completing claims related projects.
- Acquire necessary skills through in-house training for Claim Examiner II position. Achieve Level II position within 36 months from start of Claims Examiner I.
- When necessary, refers inquiries to management, dental consultants or appropriate outside organizations.
- Provides management with required production figures as requested.
- Other duties as assigned
- Personal computer skills with the ability to type 25 words per minute
- Possess the ability to use Microsoft Word and Excel
- Excellent written and oral communication skills
- Ability to research and troubleshoot problems
- Demonstrate good analytical and proofreading skills
- Attention to detail
- Good organizational skills
- Meet-exceed CPH of 30 or above
- Maintain TQM of 99% or higher
- Ability to sit and perform extensive close keyboard and PC work
- Ability to walk, talk or hear
- Occasionally required to stand and reach with hands and arms
- Ability to meet deadlines and attendance standards.
- The noise level in the work environment is usually moderate.
- This classification will be required to sign a confidentiality agreement.
- 1-3 years claims processing or related service experience
- Dental Assistant education/experience preferred
- Requires high school diploma or equivalent.
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