Claims Examiner

Job ID


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.


Principal Responsibilities

  • Processes category I, II, and Ill pended claims according to CMS's and Peoples Health's policies and procedures utilizing the Amisys Advanced and EXP Macess Doc-Flo systems.
  • Manually enters claims directly into Amisys if unable to be entered electronically.
  • Processes the Batch Error Report (BER) that lists electronic, paper, and manual claims that are not successfully imported into Amisys Advance.
  • Resets claims as needed that are in re-adjudication status (e.g. provider affiliation updates).
  • Processes the Claims Review Report (CRR), Potential Duplicate Report, and all other specialty reports as needed.
  • Ensures individual production and accuracy benchmarks are met
  • Completes ComplianceWire modules timely.
  • Operates as a team player to ensure open communication and establishes trust that supports a team environment in the unit
  • Assists with maintaining consistent departmental inventory levels.
  • Reports issues to the Claims Accuracy Supervisor.
  • Performs other duties as assigned by claims management staff.

Core Competencies

  • Successfully completes claims training to enter and process pended claims.
  • Possesses a professional, positive and energetic demeanor that exhibits support for company goals and policies.
  • Demonstrates a logical thought process in order to interpret and apply contract benefits.
  • Detail-oriented in order to work with a high degree of accuracy and attention to detail to ensure claims are entered and processed correctly.
  • Very good interpersonal skills to interact with personnel at all levels of the department to ensure a high-performing team environment and positive approach toward work and training.
  • Very good verbal and written communication skills to ensure effective, positive communication between his/her supervisor and other employees in the unit and department, as well as effectively document service forms.
  • Excellent organizational skills in order to successfully prioritize tasks and ensure individual benchmarks are consistently met
  • Customer focused and service oriented to ensure timely and accurate performance and benchmark achievement
  • Ability to work independently and complete assignments in a timely and accurate manner.
  • Possesses a high degree of confidentiality to support protection of sensitive information.
  • Ability to work a flexible schedule when required.



  • College degree preferred.
  • Excellent keystroke competency and ten key skills needed, as well as proficient PC skills including experience with Microsoft Office products in order to enter and process claims.
  • Prefer a minimum of 2 years claims processing or billing experience.
  • Prefer medical terminology and/or CPT, ICD-9 coding knowledge.


Physical Demands/Working Conditions

  • Overtime as needed.


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