Job TitleHere's what you'll be doing:Level II - Level III1 - Analyzes and processes minimum of 200 claims daily to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims2 - Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations3 - Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments4 - Assists with other research and development projects as directed by Management; obtains and maintains necessary certification for Health Insurance Marketplace CAC5 - Provides training and guidance through expert knowledge of claims administration and adjudication to Insurance Department staff; responsible for the timely response to formal appeals from members, employees, clients and providers6 - Reviews, resolves and/or escalates Level 2 claims appeals; releases claims up to the designated draft authority for Level 2 Claims Examiner7 - Works with the Customer Service Coordinator to manage and provide direction to the utilization review and case management vendor; identifies and manages claims with potential subrogated recovery8 - Ensures that claims adjudication complies with all FCPID standards and protocols; reviews claims for possible abuses and/or fraud and bring to the attention of management9 - Oversees the repricing processes to ensure the integrity of the product; investigates claims referred by staff for possible abuse and fraudWhat you'll need to be successful:Level II - Level III1 - High School Diploma or GED2 - Five (5) years of experience in medical claims processing3 - Three (3) years in customer service4 - Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards5 - Two (2) years in a lead or supervisory capacity6 - Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology7 - Knowledge of insurance principles and/or procedures8 - Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment9 - Must successfully pass all applicable background checks and drug screensBenefits you'll love:Approximately 5 weeks of paid time off annually3 weeks of paid holidaysPremium free health insuranceFlexible spending accountsShort term disabilityLife insurance401k with matchEqual Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
Insurance Claims Examiner II in crandon at Unknown Company
This position is listed as contract and onsite.