Bright HealthCare
SCOPE OF ROLE
Processes and adjudicates health insurance claims in accordance with all organizational policies, contracts, plan benefits, division of financial responsibilities, and regulatory requirements.
ROLE RESPONSIBILITIES
The Claims Examiner job description is intended to point out major responsibilities within the role, but it is not limited to these items.
- Adjudicate claims according to all claims policies, contracts, practices, and regulatory requirements
- Assist the department in meeting compliance with regulatory timeliness guidelines Meet or exceed department standard of production quota set by claim type Meet or exceed department accuracy standards Research, resolve, and (if needed) reprocess claims received through Customer Service, appeals, grievances, or audits
- Other claims duties as assigned
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- High school diploma or equivalent
- Two-to-five-year experience processing claims in a health plan, MSO, or IPA, environment
- Proficient in medical terminology, CPT, ICD10, and HCPCS codes
- Previous experience with EZ-Cap system for claims processing preferred
- Knowledge of CMS Medicare payment guidelines preferred
PROFESSIONAL COMPETENCIES
- Good verbal and written communication skills
- Good organizational and interpersonal skills
- Complex problem-solving skills
- Broad knowledge of health insurance and services delivery and functions
- Ability to work independently and meet deadlines
WORK ENVIRONMENT
- The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
We’re Making Healthcare Right. Together.
We are realizing a completely different healthcare experience where payors, providers, doctors, and patients can all feel connected, aligned and unified on the same team. By eradicating the frictions of competing needs, we are making it possible to give everyone more of what they want and deserve. We do this by:
Focusing on Consumers
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
Building on Alignment
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.
Powered by Technology
We employ our purpose built, integrated data platform to connect clinical, financial, and social data, to deliver exceptional outcomes.