Claims Examiner role at Sedgwick analyzing complex general liability claims with focus on litigation and rehabilitation and ensuring service expectations are met.
About the role
- Medical Claims Examiner processing healthcare claims for Imagenet. Ensuring compliance and accuracy in claims adjudication and processing.
Responsibilities
- Review and adjudicate medical claims, ensuring accurate coding, data entry, and application of appropriate reimbursement methodologies
- Verify patient eligibility, provider credentialing, and coverage details to facilitate accurate claims processing
- Communicate with internal resources, and internal stakeholders to resolve claim discrepancies, request additional information, or clarify issues
- Review, evaluate and process all types of claims such as Encounter data, Professional and Institutional Claims for all lines of business e.g., Commercial, Point of Service (POS) Senior/Medicare, Preferred Provider Organization (PPO), Medi-Cal, etc.
- Ensure claims payment & denial accuracy and compliance to turnaround time
- Participate in ongoing training and professional development activities
- Maintain accurate and detailed records of claims processing activities
- Identify and escalate complex or unusual claims for further review or investigation
- Handle more complex claims with multiple services, providers
Requirements
- 2+ years of experience working closely with healthcare claims or in a claims processing/adjudication environment
- Understanding of health claims processing/adjudication
- Medical terminology strongly preferred
- Understanding of ICD-9 & ICD-10
- Ability to perform basic to intermediate mathematical computation routines
- Basic MS office computer skills
- Ability to work independently or within a team
- Time management skills
- Written and verbal communication skills
- Attention to detail
- Must be able to demonstrate sound decision-making skills.
Benefits
- Comprehensive HMO Coverage - Medical & Dental HMO coverage on Day 1 plus 1 dependent
- Transportation Allowance
- Equipment will be provided
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