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 timely manner. The Claims Examiner Sr is responsible for reviewing and investigating COB information, calculating and recovering COB overpayments, as well as researching CCS eligible members and seeking recovery of CCS overpayments. Research and respond to disputes from providers. Process refunds, reversals and perform quality 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 seek recovery. This includes writing providers to request refunds.
• Research Medicare information and review claims history to identify overpayments and seek recovery.
• Review log of overpayments and research member profile to seek recoveries.
• Update logs, track all refund checks, and requests for recoupment of overpayments.
• Notify accounting as checks are processed
• Seek recovery of any CCS claims paid in error.
• Ensure that all CCS members are identified in member comments.
• Call members’ employers 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 further review.
• Review difficult claims with guidance from Claims Supervisor or Manager.
• Notify Senior Support Staff regarding other potential liability (TPL) for notification to be sent to State (DHS).
• Seek refunds of all third-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 within the company.
• Review by report procedures and refer to supervisor to establish reimbursements.
• Process claims in all areas including inpatient, outpatient, PCP and specialty areas.
• Complete reprocessing instructions as needed for processor errors and assist in training staff in all areas of claims processing.
• Process claims from members.
• Answer phone calls from providers and other claims related calls.
• Maintain productivity and quality in accordance with established guidelines.
• Perform other job-related duties as required.
• Adheres to all 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.

Nice-to-haves

• Health Maintenance Organization (HMO) claims payment processing is highly desirable.

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