Under the direction of the Claims Supervisor, the claims processor is responsible for receiving claims and processing adjudicating the claims in an expedient manner. Responsible for provider claims verification and adjudication. Responsible for meeting the performance measurement standards for productivity and accuracy cor the specifics claims. HCFA and UB.Ensure the privacy of security of PHI, as outlined in health plans and policies relating to HIPAA compliance.

The Claims Examiner is responsible for the following:

• Verifying and adjudicating provider claims in moderate complexity categories.
• Adjudicate all professional and outpatient facility claims including Coordination of Benefits, denials, and reduction in service notifications.
• Responsible for meeting or exceeding production and quality standards for specific types of claim forms, professional (HCFA) and/or institutional (UB).
• Route claims that cannot be finalized.
• Research, resolve, and respond to inquiries and problems of a moderately complex nature.
• Follow documented claims policies and procedures.
• Interface with other departments, when necessary, regarding claims issues.
• Participate in Claims Department staff meetings, and other activities as needed.
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in health plans policies and procedures relating to HIPAA compliance.
• May be responsible for mentoring newer associates.
• Perform other duties as assigned including participation in all safety programs which may include assignment to an emergency response team.