SUMMARY OF POSITION:
Under the guidance and direction of the Team Leader (Claims
Supervisor), the Process Executive (Claims Examiner) is responsible
for the quality production, adjudication, and cycle time of claims.
This position will adhere to all corporate guidelines while
processing claims in a timely and efficient manner and placing a
strong emphasis on quality work.
MAJOR DUTIES AND RESPONSIBILITIES:
MEET and maintain individual quality and productivity standards
and claim cycle time.
INTERPRET and apply appropriate processing policies, procedures
and guidelines while interacting with on-line systems
PROCESS, review and investigate facility or professional claims
by applying appropriate contractual benefit provisions, riders,
waivers, and provider contracts.
PROCESS claim pends to correct and/or finalize the claim on a
timely and accurate basis.
UTILIZE knowledge of procedure codes (i.e. CPT), diagnosis codes
(i.e. ICD-9), and POS/TOS codes to render accurate claims
ANALYZE patient and medical information to identify whether
investigation for Coordination of Benefits, Subrogation, Worker's
Compensation or No Fault is necessary and to be encountered.
INFORM management of processing, systems, procedural issues
and/or problems that may be encountered.
INITIATE system generated and/or form letters (e.g. requests for
Medical Records or claims denials).
PERFORM various related duties as assigned.
This description is not an exhaustive list.
Qualifications - External
Education/Experience: The ideal candidate will possess a high
school diploma (two years of college preferred) and preferably with
6 months - 2 years on claims adjudication experience or in a
managed care experience, or comparable experience in medical
billing/coding. The qualified candidate must be able to
successfully complete the Claims Training curriculum.
Skills/Knowledge/Competencies: The ideal candidate will
demonstrate proficiency in medical terminology, procedure and
diagnosis coding in order to ensure comprehension of the overall
claims process. Familiarity with the universal facility or
professional claim/billing forms is required. The ability to
perform in a high production environment and meet or exceed
individual and departmental productivity and quality standards is
required. Strong written and oral communication skills and
analytical ability with attention to detail are essential to
success. The incumbent must have the ability to work independently
to complete assigned tasks.
Cognizant will only consider applicants for this position whom
are legally authorized to work in the United States without
requiring company sponsorship now or at any time in the future.