Medical Claims Examiner

The Medical Claims Examiner makes fair, consistent and timely claims decisions based on plan documents. The candidate will verify eligibility, process claim payments and/or denials of medical, COB, claims adjustments, pre-determinations as assigned. The Claims Examiner will also be responsible for reviewing and auditing claims including workers’ comp and subrogation files as well as maintaining an excellent processing accuracy error ratio. The candidate will be responsible for accurately obtaining additional information from hospitals, doctors, attorneys state agencies and participants when necessary.The ideal candidate will be detail-oriented, efficient, courteous and discreet.

Heartland Health & Wellness Fund is 39,000 members strong, comprised of plan participants, spouses and dependents in Illinois, Indiana, Ohio, Kentucky, Michigan, West Virginia and Wisconsin represented by the United Food and Commercial Workers (UFCW) union. As a regional health plan, Heartland provides quality health and wellness benefits and eligibility information to its plan participants and their families.

Responsibilities

  • Properly document correspondence and claims adjudication notes and decisions as well as any other required information.
  • Review incoming claims correspondence and update system accordingly.
  • Embrace new systems and processes to increase efficiency.
  • Maintain thorough and current knowledge of Plan Documents including eligibility rules, benefit provisions and payment procedures.

Requirements

  1. High school diploma or GED equivalent – required.
  2. Knowledge of medical terminology preferred.
  3. Two or more years’ experience with medical claims adjudication – preferred.
  4. Two years college or Certified Professional Coder Certification – preferred.Typical office setting experience including filing, typing, scanning, copying, computer knowledge – required.
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