Job Description:

Claims Examiner Senior

Sunshine Staffing is seeking a Claims Examiner  for an office setting! This individual is able to provide leadership, assistance, and guidance in the day-to-day functions of the Claims department. They will be able to communicate with and provide support for the supervisors while maintaining professional standards.

Responsibilities

• Provides technical and/or process direction to Claims Examiners at all levels, ensures claims are completed and adjusted within the department’s performance guidelines, oversees that team achieves results and serves as project and/or system testing support for the department.
• Monitors staff’s workload in Facets queues, reviews claim inventory discrepancies and assigns work around absences and other scheduling conflicts.
• Identifies, advises, and supports management team of claims processing trends, discrepancies, problems, and issues, and recommends courses of action.
• Informs management of new procedures and ideas for continuous process improvement/implementation, training, and quality audits, and coordinates with department Trainer, Business System Analyst, and Process Improvement Coordinator.
• Compiles, reviews, and analyzes management reports and takes appropriate action.
• Performs quality review or audit on new hires and any examiners placed on quality-focused audit requirements.
• Acts as the subject matter expert for complex claim types, adjustments, training, and provider claims inquiries, procedural or special requests adhering to claims processing policies and procedures.
• Informs Supervisor/Manager of department inventory status (high volume, aging claims, etc.)
• Represents Supervisor/Manager at meetings in their absence as appropriate.
• Other projects and duties as assigned.
  
  

Qualifications

• High school diploma or equivalent work experience is required.
• 3+ years of related claims processing experience required.
• Associate degree or bachelor’s degree in Health Care Management or related field preferred.
• Team leadership role in a managed care environment preferred.
  
  
  Necessary Attributes
  
• Interact with teams, encourage, negotiate, and influence others using a positive approach.
  
• Troubleshoot claims processing technical problem areas.
• Remain objective when dealing with difficult topics and/or giving feedback to peers.
• Create reports and calculations.
• Communicate clearly and concisely verbally and in writing, including presentations and when communicating with individuals of diverse backgrounds.
  
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
• Strong knowledge in medical claims administration/processing, including medical terminology, revenue codes, International Classification Disease (ICD)-10 and Healthcare Common Procedure Code System (HCPCS) codes.
• Claims management processes, industry pricing methodologies, such as Resource Based Relative Value Scale, Medicare/Medi-Cal Fee Schedules, etc.
• Medi-Cal and/or Medicare Claims regulatory guidelines.
• Claims Benefit interpretation and administration.
• Department performance and inventory trending reports, their purpose and how to interpret them.
• Organize, prioritize work activities, problem-solve, analyze, and interpret data.

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:

• 401(k) savings plan
• Awards and recognition programs
• Benefit eligibility is dependent on employment status.
• Competitive pay & weekly paychecks
• Health, dental, vision, and life insurance

Sunshine Enterprise USA is an “Equal Opportunity Employer—Minorities, Females, Veterans and Disabled Persons”