Bright HealthCare
Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives apply to join our team.
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.