Medical Claims Examiner
Responsibility A: Adjudicate Claims received into processing.
- Task #1: Thoroughly reviews, investigates and adjudicates claims daily, working oldest to newest claim in 30 days or less, and 98% of the time.
- Task #2: Examiner should process a minimum of 14 claims per hour, or a minimum of 98 claims per day.
- Task #3: Conducts review and investigation of pended claims and follow up with internal and external departments to finalize claims resolution within 30 days.
- Task 4: Macess requests are processed within 30 days of receipt, with a 98% accuracy, to ensure timely resolution of claims, in adherence with HHSC regulatory requirements.
Responsibility B: The claims are processed accurately as defined by standard guidelines.
- Task #1: The claims should be adjudicated with a 98% procedural accuracy rate monthly as reviewed by weekly audit reports.
- Task #2: The claims should be adjudicated with a 98% accuracy rate monthly as reviewed by returned claims for adjustment review.
- Task #3: The claims that are manually adjudicated must have notes entered as reviewed by weekly audits, check run, returned claims, management review 98% of the time. Task #4: Clear concise documentation/notes must be entered for each claim reviewed, which provides a historical reference of how the claim was processed at the time of adjudication.
Knowledge: Required for completely satisfactory performance in this job is a
- Knowledge of ICD-9, CPT/HCPCS coding methodologies (and their successors)
- Claims examination functions
Education: The formal education required for completely satisfactory performance in this job is :
- High School Diploma or GED and
- 2 years claims experience.