Job Description
Overview
BroadPath is hiring a work from home, detail-oriented medical Claims Examiner looking to make a significant impact in the healthcare industry. Join our remote team as a Claims Examiner and play a crucial role in ensuring the financial integrity and efficiency of our healthcare organization. The Claims Examiner’s will be responsible for accurately processing a wide range of claims, identifying and resolving complex issues, and providing top-notch customer service to our valued providers and members.
Responsibilities
- Adjudicate a variety of claims, including routine and complex cases, resolving system edits and audits for both hardcopy and electronic submissions.
- Effectively communicate with providers and members to address issues related to claims, eligibility, and authorizations.
- Generate emergency reports and authorizations for claims lacking prior approval.
- Process third-party liability and coordination of benefit claims in accordance with company policies.
- Assist in the review of stop loss reports to identify members approaching reinsurance thresholds.
- Escalate potential system programming issues to supervisors for resolution.
- Provide guidance and training to less experienced claims processors.
- Recognize and appropriately route claims for carved-out services according to plan contracts.
- Apply knowledge of plan contracts, provider pricing, member eligibility, referral authorization procedures, benefit plans, and capitation arrangements.
- Collaborate with the Accounting team to ensure accurate posting of claims information to general ledger accounts.
- Work closely with Customer Service and Provider Services departments on large claim projects and adjustments.
- Interpret benefit and plan details for customers through the use of the cut-log system when necessary.
- Assist senior examiners in the adjustment of complex claims.
- Perform other duties as assigned by management.
Qualifications
- High school diploma or equivalent required
- 1-3 years of medical claims processing experience
- Knowledge of ICD-9, CPT, HCPC, and Revenue Coding
- Strong analytical and problem-solving skills to address claim issues and troubleshoot problems
- Excellent communication and customer service skills to effectively interact with providers and members
- Attention to detail and the ability to maintain focus in a high-volume, production-oriented environment
- Proficiency with claims processing software and technology
- Understanding of medical terminology, coding, and healthcare industry regulations
- Ability to learn and apply complex claims procedures and policies
- Teamwork skills to collaborate with colleagues and provide training or support
- Adaptability to work under demanding performance standards for production and quality
Preferred Qualifications:
- Commercial Claims Experience, QNXT