Position Purpose and Scope
The Claims Examiner ensures category I, II, and Ill pended claims are adjudicated according to CMS's and Peoples Health's policies within established timeliness and accuracy benchmarks, as well as other claims processing responsibilities.
The Claims Examiner interprets claim pends in the Amisys Advanced System, while utilizing the EXP Macess Doc-Flo system. This position makes logical benefit decisions to adjudicate Medicare claims utilizing internal fee schedules, and a variety of other programs and screens. Some pended claims require assistance from other departments to process, such as: Medical Management, Provider Affiliations, Member Services, and Configuration. This position also processes the Batch Error Report, manually enters claims directly into Amisys, and resets claims as needed that are in a readjudication status. The Claims Examiner must meet his/her established production and accuracy benchmarks.
Ability to work a flexible schedule when required.
Physical Demands/Working Conditions