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Claims Examiner

Company: Generali Global Assistance
Location: Lehigh Acres
Posted on: January 16, 2022

Job Description:

Job Summary:

Reports to Claims Manager. Works closely with Account Managers, and Client Service Coordinator to coordinate the daily work on assigned clients to process claims. Responsible for conducting investigations, evaluations and disposition of coverage on assigned accounts.

Principal Duties and Responsibilities:
Proficient in assigned clients policies and procedures
Total comprehension of all types of medical claims billing
Total comprehension of ICD-9/10 and CPT codes
Extended knowledge on network pricing logic in the operating system
Re-prices any type of domestic or international claim
Identifies and corrects potential claim problems, such as balance billing or incorrect re-pricing
Identifies and updates any provider database discrepancies in the operating system and report to Claims Manager if deemed necessary
Answers phones in a clear, polite speaking voice. Provides requested information in a timely, accurate, and professional or directs the call to the proper party
Resolves all types of problem claims
Prepares MIS request for any data discrepancy in the operating system if identified
Apply accurate discount rate on manual claims repricing: GD/CMN contract
Establish necessary contacts to affiliate PPOs to ensure pricing accuracy
Process assigned adjustments timely
Ensures that claims are processed according to GMMI's Quality Management Policy Guidelines with a focus on turnaround time, accuracy and maximization of discount opportunity
Conducts bill reviews for all claims and places claims over $50,000 on hold for Director of Claims or VP of Healthcare Services to audit
Identifies needs to request additional information in order to adjudicate a claim (e.g. medical records), communicates with Claims Support Team and Client Service Coordinators to ensure that information is requested
Reviews medical records for claims adjudication purposes
Other responsibilities as assigned by Claims Manager, VP of Healthcare, and Senior Management

Required / Desired Knowledge, Experiences and Skills:
A minimum of 1-2 years prior experience in claims processing is preferred
Claims data entry ability minimum of 80-100 claims per day
Ability to process 40-50 claims per day for adjudication
Prior knowledge and experience in healthcare and insurance field for processing medical claims
Complete Knowledge of ICD-9/10 and CPT procedure codes and all other insurance coding methodologies.
Excellent interpersonal skills necessary to interact positively with clients, providers, and employees
Must be able to represent the organization in a professional and knowledgeable manner
Excellent verbal and written communication skills with ability to manage and prioritize multiple tasks
Computer skills necessary to work effectively: Windows Microsoft Word and Excel
Ability to work well under pressure in a production oriented environment
Excellent problem solving skills and capability to troubleshoot the most difficult claim issues
Proficient in GMMI claims processing, claims repricing policies and its operating system

Education/Certifications:
High School Diploma or Equivalent (GED) required
Billing/coding certificate preferred

Physical Working Environment:

While performing the duties of this job, the employee is required to stand; walk; sit for long periods of time; use of hands to grasp, handle, or feel; reach with hands and arms; finger dexterity; talk; hear. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties and skills required of employees so classified.

GMMI is an Equal Opportunity Employer M/F/Disability/Veteran

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Keywords: Generali Global Assistance, Lehigh Acres , Claims Examiner, Other , Lehigh Acres, Florida

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