JOB DESCRIPTION

Title: Claims Examiner II

Reports to: Claims Supervisor

Position Overview: Responsible for reviewing and processing Medicaid claims for payment or denial. Ensuring compliance with My Choice Wisconsin and/or Medicaid submission/billing requirements, benefits and internal policies and procedures as defined in the Claims Processing Manual and/or separate SOPs (standard operating procedures). Also includes related activities as directed.

ESSENTIAL FUNCTIONS & DUTIES

(*_all activities performed in accordance with established policies & procedures of the specific account)*_

Resolve Claims: Review batch claims assigned on a daily basis that are in an Error, Pended, or Payable status. Resolution may include but is not limited to pricing, assigning benefits, selecting patient, selecting provider, clearing and/or adding specific error, pend or payment Explanation of Payment Codes, etc.

Process Claims: Apply plan provisions to medical and behavioral health claims in batch according to Medicaid and/or Medicare requirements, CPT billing standards and current claim policies and procedures. Coordinate benefits with primary insurance as applicable. Meet internal and client quality and turn-around time requirements.

Production and Quality: Claims turn-around time from receipt to paid as well as quality standards are contractually required by My Choice Wisconsin and must be met. The volume of claim receipts varies day to day so production required to continually meet the requirements will vary respectively

Related Activities (Examples down the road):claim adjustments, managing refund requests and receipts, assisting with recoup investigation, reviewing Customer Service requests for reconsideration, and other support role activities

QUALIFICATIONS:

Education and Experience:

Required:

• High school diploma or equivalent. College degree preferred.
• 3 – 5 years of experience processing medical insurance claims. Medicaid, Medicare, HMO or other Managed Care experience preferred (Billing experience may be included or substituted if applicable)

Skills, Knowledge and Abilities:

• Knowledge of HCPCS, ICD and CPT coding, CMS1500 and UB04 claim forms, coordination of benefits, third party liability
• Basic understanding of health insurance, Medicare, Medicaid
• Attention to detail and ability to multi-task
• High degree of integrity
• Excellent verbal and written communication skills
• Exhibit a pleasant and professional manner
• Dependable
• Customer service focus and team player
• Must use computer, fax, copier, scanner, telephone
• Must handle PHI and maintain HIPAA confidentiality at all levels

In accordance with the American with Disabilities Act, the above is intended to summarize the essential functions of and requirements for the performance of this job. It is not meant to be an exhaustive list of miscellaneous duties and responsibilities that may be requested in the performance of this job.

Job Type: Full-time

Pay: $18.00 - $25.00 per hour

Benefits:

• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Physical setting:

• Office

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Ability to commute/relocate:

• Milwaukee, WI 53207: Reliably commute or planning to relocate before starting work (Required)

Work Location: One location

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