Health Care Claims Examiner Job Opportunity Raleigh Area

Health Care Claims Examiner Job Description

Essential Functions of Job

The Claims Examiner is responsible for independently reviewing, adjudicating and finalizing professional and institutional electronic and paper medical claims in accordance with state, federal and health plan regulatory requirements. The claims examiner effectively manages workload and prioritizes assignments while being able to work without significant guidance. The role of the claims examiner will utilize appropriate reference materials and policies to research information and process claims accurately, as well as meeting established quality and production performance benchmarks to include required research and review of applicable documentation.

Job Qualifications

REQUIRED:

1. High school graduate.

2. Knowledge of and working experience with ICD-9, CPT and HCPC coding systems.

3. Thorough knowledge of medical terminology and claim processing procedures/systems.

4. Basic understanding of Microsoft Word and Excel applications.

5. Three (3) years prior claims processing experience in an IPA or HMO related setting.

6. Knowledge of FACETS, QNXT, AMISYS or Xcelys Platform(s)

PREFERRED:

1. PowerMHS Platform Experience

Knowledge of FACETS, QNXT, AMISYS, Xcelys or similar claims platform

Experience as a Claims Examiner in a Health Plan or TPA

Knowledge of PwerMHS is strongly preferred