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Claims Examiner Senior Specialist - REMOTE
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
Responsible for the accurate and timely review of complex claims in accordance with applicable contracts, state and federal regulations, health plan requirements, policies and procedures, and generally accepted business practices.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
- Analyzes professional and hospital claims for accuracy according to set dollar thresholds and meets and maintains production and quality standards.
- Reviews authorization and/or provider's contract and adjudicates claims accordingly.
- Perform any correspondence, follow-up and any projects delegated by claims supervisor.
- Provide assistance to the customer service department with escalated member issues.
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- General office equipment experience (i.e. photocopier, fax, calculator, ability to operate a PC and previous exposure to the Microsoft Windows environment).
- Must have an excellent understanding of health and managed care concepts and their application in the adjudication of claims.
- Strong working knowledge of ICD.9.CM, CPT, HCPCS, RBRVS coding schemes and medical terminology.
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience preferred to perform the job.
- High School Diploma or Equivalent preferred
- 3-5 years of claims processing experience in a PPO, self-funded, and/or HMO setting preferred
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to work in sitting position, use computer and answer telephone
- Ability to travel
- Light physical effort (lift up to 10lbs). Regularly needs to be able to bend, stoop and reach to file.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Office Work Environment
- Approximately 0% travel may be required
Employment practices will not be influenced or affected by an applicant’s or
employee’s race, color, religion, sex (including pregnancy), national origin,
age, disability, genetic information, sexual orientation, gender identity or
expression, veteran status or any other legally protected status. Tenet will
make reasonable accommodations for qualified individuals with disabilities
unless doing so would result in an undue hardship.
Tenet participates in the E-Verify program. Follow the link below for additional information.
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