Associate Claims Examiner

Position Overview

The Associate Claims Examiner is responsible for all intake processes, claim transcription and the releasing of simple claim pends in support of Claims Operations ensuring claims are processed according to state and federal regulations and meet the company's contractual obligations.

• 
  

  Responsible for the intake of all Claims mail regardless of submission method (USPS, Fax, E-forms, Email, etc.)

  
  
• 
  

  Sort, count and batch daily claims receipt by type of claim (institutional/professional) for either claims production team or scanning vendor

  
  
• 
  

  Identify non-clean claims, and create sendback letter to return the claim to the provider

  
  
• 
  

  Analyze rejection report from outsourced vendor, by reviewing rejections and determining if the rejection is accurate or not.

  
  
• 
  

  Identify trends and patterns of incorrect provider submissions, and work with Supervisor and Provider Relations for outreach and education to providers.

  
  
• 
  

  Interpret and validate submitted requests for adjustment and reconsideration requests. including the upload of supporting documentation.

  
  
• 
  

  Create system request to create and/or update provider demographic data for non-par provider claims submitted with a W9.

  
  
• 
  

  Accurate transcription of professional (HCFA) and Institutional (UB-92) claims into the claims processing system

  
  
• 
  

  Acknowledge, analyze, accept and track Electronic Adjustment and Reconsideration requests from providers

  
  
• 
  

  Accurate analysis and releasing of claim pend(s) to complete claim processing.

  
  
• 
  

  Maintain daily inventory of claims report for claims statistics reporting to supervisor and manager

  
  
• 
  

  Track batches of claims that are given directly to claims staff on log sheets

  
  
• 
  

  Prepare, list, track and retrieve claims selected for off-site storage

  
  

• 
  

  Meet daily production and quality standards as established by management

  
  
• 
  

  Organize and accurately maintain filing system of confidential information and secure them in accordance with HIPAA

  
  
• 
  

  Acts as a liaison for department with an outside storage company - must be able to move 50 lbs.

  
  
• 
  

  Follow established day-to-day administrative processes, review DTPS, and make process improvement suggestions to same

  
  
• 
  

  Has a thorough working knowledge of all tasks within the department

  
  
• 
  

  Act as a resource to Claims Operations

  
  
• 
  

  Train staff as assigned

  
  

• 
  

  Assist in special projects and other duties as assigned

  
  
• 
  

  Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

  
  

Qualifications

Required:

• 
  

  High School graduate or GED equivalent

  
  
• 
  

  Minimum of one (1) year previous office experience

  
  
• 
  

  Time management, prioritization, and strong organizational skills with a high level of attention to detail and accuracy

  
  
• 
  

  Proven success working in a fast paced, task driven work environment

  
  
• 
  

  Ability to multitask, be adaptive to change, and remain flexible to shift between assignments

  
  
• 
  

  Excellent interpersonal skills to build rapport and a relationship with team members; ability to work effectively in a focused and motivated team environment

  
  
• 
  

  Experience with Medical Terminology

  
  
• 
  

  Proficient written and verbal communication skills

  
  
• 
  

  Accurate transcribing of claims data in the claims processing system

  
  
• 
  

  Computer competence in Microsoft (Office, Excel, Word, etc.); computer literate with the ability to learn new software skills.

  
  
• 
  

  Display a hard-working attitude and ability to work independently, taking ownership of tasks and meeting deadlines

  
  
• 
  

  Must be able to move up to 50 lbs.

  
  

Preferred:

• 
  

  Some college

  
  
• 
  

  Prior medical billing office experience

  
  
• 
  

  Familiarity with health insurance claim forms (HCFA 1500/UB-04)

  
  
• 
  

  Understanding of HIPAA requirements related PHI/PHII

  
  

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.