Job summary: The Claims Examiner II accurately reviews, researches and analyzes professional, ancillary and institutional inpatient and outpatient claims.
Duties and responsibilities:
Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines.
Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims.
Comprehensive knowledge of various fee schedules and CMS pricers for outpatient/inpatient institutional, ancillary and professional claims, including, but not limited to Medicare fee schedules, DRG, APC, ASC, SNF-RUG.
Ability to identify and report processing inaccuracies that are related to system configuration.
Process all types of claims, such as, HCFA 1500, outpatient/inpatient UB92, high dollar claims, COB and DRG claim
Reviews. processes and adjudicate claims for payment accuracy or denial of payment according to Department’s policy and procedures.
Processes all claims accurately conforming to quality and production standards and specifications in a timely manner.
Documents resolution of claims to support claim payment and/or decision.