Medical Claims Examiner - IT Staffing
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Medical Claims Examiner

Medical Claims Examiner

Contract
   |   
Houston, TX
   |   April 13 2018

Description

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 Task #4: Clear concise documentation/notes must be entered for each claim reviewed, which provides a historical reference of how the claim was processed at the time of adjudication.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.