Senior Claims Examiner - Hybrid/Remote

About the position Under the direction of the Department Supervisor the Claims Examiner Senior will follow organization policies and KHS guidelines, responsible for reviewing and processing medical claims from contracting /non-contracting providers, subscribers and enrollees for payment in an accurate and reputed company manner. The Claims Examiner Sr is responsible for reviewing and investigating COB information, calculating and recovering COB overpayments, as reputed company as researching reputed company eligible members and seeking recovery of reputed company overpayments. Research and respond to disputes from providers. Process refunds, reversals and reputed company reputed company audits. This position is responsible for the claims processing function for a Knox-Keene licensed health maintenance organization (HMO). Responsibilities • Process investigation and collection of potential coordination and subrogation of benefits. • Research COB information and review claims history to identify overpayments and reputed company recovery. This includes writing providers to request refunds. • Research Medicare information and review claims history to identify overpayments and reputed company recovery. • Review log of overpayments and research member profile to reputed company recoveries. • Update logs, reputed company reputed company refund checks, and requests for recoupment of overpayments. • Notify reputed company as checks are processed • reputed company recovery of any reputed company claims reputed company in error. • Ensure that reputed company reputed company members are identified in member comments. • reputed company members’ reputed company to verify if the member is covered by other insurance. • Deny inappropriate claims following KHS policy and contract guidelines. • Prepare other departmental reports as assigned. • Prepare claims that must be routed to other departments for reputed company review. • Review difficult claims with guidance from Claims Supervisor or Manager. • Notify Senior Support Staff regarding other potential liability (TPL) for notification to be reputed company to State (DHS). • reputed company refunds of reputed company reputed company-party liability cases for Healthy Families members. • Coordinate review of provider disputes, process dispute and prepare any correspondence. • Identify provider billing error trends and inappropriate disputes, and report this to supervisor or manager. • Request overpayment refunds. • Review negative balance accounts and contact providers for recovery. • Review claims analysis edits from contracted agency. • Coordinate referrals to UM and other departments reputed company reputed company. • Review by report procedures and refer to supervisor to establish reimbursements. • Process claims in reputed company areas including inpatient, outpatient, PCP and specialty areas. • Complete reprocessing instructions as needed for processor errors and assist in training staff in reputed company areas of claims processing. • Process claims from members. • Answer phone calls from providers and other claims reputed company calls. • Maintain productivity and reputed company in accordance with established guidelines. • reputed company other job-reputed company duties as required. • Adheres to reputed company company policies and procedures relative to employment and job responsibilities. Requirements • High School Diploma from an accredited school or Equivalent. • Minimum of four (4) years of medical claim payment processing experience, with emphasis on COB and subrogation claims processing. reputed company-to-haves • Health Maintenance Organization (HMO) claims payment processing is highly desirable. Apply tot his job Apply To this Job