Claims Examiner II

Claims Examiner II

Location: Birmingham, AL

Job Description

The Claims Examiner II will administer all claims adjudication processes in accordance with contractual agreements along with VIVA HEALTH guidelines. This position will assist with additional duties such as reports and following up with departments on routed claims. Must be available to work during the core hours of operation, 8am to 5pm Monday through Friday, and overtime as required.

Key Responsibilities

• Adjudicate claims submitted by providers and members assigned via claims workflow.


• Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated.


• Correctly match authorizations to ensure claims are processing appropriately based on established guidelines.


• Work with internal departments to resolve issues preventing claims from processing or enhancing processing capabilities.


• Meet and maintain performance and quality measurements as required by the department to meet regulatory compliance standards.

REQUIRED:

• At least 1–2 years of experience with claims processing


• 2 years of college or equivalent claims adjudication experience


• Ability to thrive in a production environment where quality and quantity are highly measured, including recognizing and correcting quality errors


• Demonstrate excellent customer service skills through written and verbal communication


• Organized, detail oriented, and skilled at prioritizing and multitasking


• Ability to work in a team environment, remain flexible to changes, and recognize responsibilities, actively participate with others to accomplish assignments and achieve desired goals


• Knowledge of medical terminology, ICD, CPT, and HPCS


• Basic computer skills including Microsoft Word, Excel, and Outlook


• Understanding of Claims Payment System in order to process claims, prepare reports and correspondence

PREFERRED:

• Professional and/or hospital claims adjudication experience, preferably in the healthcare/medical field


• CRT data entry experience