Job Description

Job Description

Job Description

Our client is seeking a Sr. Medical Claims Examiner for a leading insurance company in RI, in a temporary to permanent hire position.
This role acts as the single point of contact for their assigned accounts for any claim related issue. They
are the liaison/advocate between the provider and internal departments. The Senior Claim Adjuster works directly
with practice managers, via phone, email and in-person meetings on a regular basis to resolve outstanding claim
issues. This role works with our Provider Contracting and Provider Relations departments to assist in managing the
operational aspects of the provider relationship, and will attend internal meetings to present their research and
findings on claims issues. This role serves as a claims subject matter expert (SME) and is responsible for incoming
inquiries regarding current claims and escalated issues. Collaborates in strategic planning for their assigned
accounts. Works collaboratively with business and operational units to ensure prompt resolution of open issues. You will investigate, analyze, and determine the extent of the organization's liability in various claims, and process for payment.

Responsibilities, include, but not limited to:

• Serves as the SME and Lead on functional deliverables ensuring optimal efficiency in all areas of responsibility
• Tracks and maintains all known issues, including the operational provider issue logs, and implements work plans to improve claims accuracy and systemic issues that decrease efficiency or provider satisfaction.
• Conducts extensive research on complex payment inaccuracies and documents root cause analysis and mitigation
• Receives and responds timely to correspondence on escalated issues
• Performs any necessary claim adjustments for overturned determinations directly in the HealthRules system
• Responsible for the review and processing of claims according to plan benefits and contractual terms.
• Request appropriate adjustment via AWD to the Claims BPO
• Attends ad-hoc and regularly scheduled operational meetings with provider community within and outside of the organization

Qualifications:

• Associates degree or equivalent work experience
• Minimum of 5 years experience with a managed care or health care related organization (HMO/Medicare/Medicaid)
• One or more years' experience working in direct relation with the community provider (claim resolution, GAU, provider relations, etc.)
• Understanding and knowledge of claims adjudication, processing and analysis
• Understanding of provider reimbursement mechanisms
• Proficient with MS Word and Excel, PowerPoint and Outlook
• Excellent written and verbal communication skills
• Knowledge of HIPPA standards and CMS guidelines
• Deadline and detail-oriented

Interested candidates must be able to pass a background check.

This is a 37.5- hour workweek, Monday through Friday on site.

For immediate consideration please submit your resume.

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