Claims Examiner

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing Whole-Person care to Senior and Medicaid populations. The Medical Claims Examiner is responsible for processing medical services claims, ensuring accuracy, and responding to provider or client inquiries in a timely manner.

Responsibilities

• Processing of professional and facility medical services claims by reviewing and inputting data into the claims payment system using standard policies, procedures and guidelines
• Must meet quality/accuracy standard of 95% and production standards of 100-125 claims/day
• Forward claims to appropriate departments for Med Review, Eligibility, etc
• Verification of coverage and contract interpretation
• Pursues and follows up on open and pended claims promptly and independently
• Researches and investigates claims with multiple coverage and complexity to determine if claim is payable in accordance with various policy provisions. If payable, determine eligible payee(s) and payment amounts. If not payable, develop detailed letter of explanation based on policy provisions and claim documents
• Critical thinker who can maintain focus and stay on task with minimal supervision
• Participates and practices principles of continuous quality improvement

Skills

• High school diploma required; college degree preferred
• Minimum 1-3 years of medical claims processing experience in Managed Care
• Strong experience and knowledge of medical claims, Medicare/Medicaid guidelines, ICD-10, HCPCS / CPT Coding, HCFA 1500's & UB04's
• Strong communication, analytical, organizational and problem-solving skills
• Excellent time management skills
• Proficient with Microsoft applications (Word, Excel, Outlook) and database systems
• Must be able to read and interpret documents such as processing and procedure manuals, medical terminology and claims rules and regulations to appropriately develop the claim
• Ability to write routine, professional correspondence using correct grammar and spelling
• Must be able to identify and define problems; collect data; establish facts and draw valid conclusions
• Must be able to consistently interact with customers in a professional and respectful manner
• This role requires FT in-office presence for the first 60 days of employment. Hybrid schedule available after initial training period
• College degree preferred
• EzCap Claims payment systems knowledge is a plus but not required

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