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Claims Examiner

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Req #:
11102

Job Location(s):
Brooklyn, NY

Zip Code:
11220

Category:
Claims

Agency:
Elderplan

Status:
Regular Full-Time

Office:
Office-based

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

Why work for MJHS?:

When you work with us you will receive comprehensive and affordable health and financial benefits, in addition to generous paid vacation, personal and holiday time that you won't find at our competitors. Do you receive a paid day off for your birthday now? No?  You will here!  You will also receive the training, tuition assistance and career development you desire to help you achieve your career goals.  You take care of our patients, residents and health plan members, and we will take care of the rest!

 

Benefits include:

  • Sign-on Bonuses OR Student Loan Assistance for clinical staff
  • FREE Online RN to BSN and MSN degree programs!
  • Tuition Reimbursement for all full and part-time staff
  • Dependent Tuition Reimbursement for clinical staff!
  • Generous paid time off
  • Affordable medical, dental and vision coverage for employee and family members
  • Two retirement plans! 403(b) AND Employer Paid Pension
  • Flexible spending
  • And MORE!

Responsibilities:

Investigates and processes claims episodes based on claims information submitted by provider and departmental policies and procedures. Reviews, investigates and adjudicates claims for medical, facility, home health care, hospice and vision services which involve the application of contractual provisions in accordance with provider contracts, authorizations and Medicare regulations. Processes claim suspensions from the system to correct processing discrepancies and other edits by reviewing online information. Investigates, intervenes, communicates and follow-up orally or in writing with a variety of internal and external sources. Evaluates claims to ensure payments are for the services rendered. Evaluates DRG grouping and pricing information. Analyzes patient and medical information to identify COB, Workers Compensation, No-fault and Subrogation conditions and coordinates benefits with other carriers, when applicable. Processes adjustments to claims.

Qualifications:

  • Two years of college or an equivalent combination of education and experience plus four years of related claims processing experience, preferably working in an HMO or Medicare managed care environment
  • Knowledge of medical terminology, DRG, ICD-9, CPT-4 and HCPCS coding is required
  • Familiarity with Medicaid and Medicare regulations a plus
  • Must be able to problem solve and apply logic in a variety of situations where limited policies and procedures exists
  • Excellent oral and written communication skills, good organization¬†skills plus ability to use Microsoft Word and Excel required
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