Claims Management - Claims Examiner, Medical
Our goals are to provide excellent service, utilize advanced technology, and proficiently deliver results. To accomplish these goals, we constantly seek individuals who look for ways to do things better. We are a company whose
cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement.
Tabula Rasa HealthCare (TRHC) is a leader in providing patient-specific, data-driven technology and solutions that enable healthcare organizations to optimize performance to improve patient outcomes, reduce hospitalizations, lower healthcare costs, and manage risk. Medication risk management is TRHC’s lead offering, and its cloud-based software applications, including EireneRx® and MedWise™, provide solutions for a range of payers, providers and other healthcare organizations.
TRHC empowers our employees to provide excellent service, utilize advanced technology, and proficiently deliver results. Our 32Fundamentals are what we are and who we are. Our culture cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement. As a part of our team, you will help us bring innovative service models to healthcare, improving patient outcomes.
PeakTPA provides services that optimize your organization’s financial management and fulfill regulatory requirements for health plan functions. Our expertise in health plan management, particularly in PACE, means you can focus on delivering high-quality care to your participants.
Job Description: Claims Examiner
Summary: Under the supervision of an assigned Claims Supervisor, the Claims Examiner is responsible for processing claims and meeting defined quality and productivity standards.
Claims Processing and Payment
Evaluates claims for completeness and validity to determine payment/denial according to provider contracts, authorizations, and Medicare processing guidelines
Processes various Medicare and Medicaid claim types, including Professional, Facility and Dental claims
Accurately analyzes and interprets provider contracts
Researches claims and makes appropriate adjustments
Implements the TRHC 32 Fundamentals into daily work
Communicates clearly and concisely, with sensitivity to the needs of others
Maintains courteous, helpful and professional behavior on the job; displays a willingness and ability to be responsive in a warm and caring manner to all customer groups; consistently cooperates and supports organization in problem solving issues; ensures customer satisfaction; will support the success of the entire team; establishes and maintains effective working relationships with co-workers
Follows all Policies and Procedures and HIPAA regulations
Maintains a safe working environment
Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees
Establishes and maintains effective working relationships with co-workers
Participates in any required training sessions/seminars
Participates in special projects as requested
Supervisory Responsibility: None
FLSA Status: Non-exempt
Knowledge, Skills and Abilities:
Education/Experience – Educational requirements include a high school diploma or equivalent.
Two years of claims processing experience with an insurance company or TPA is required. Claims processing experience with PACE or Medicare Advantage is strongly preferred.
Requires working knowledge of ICD-10, CPT, Revenue, and HCPCS coding, along with understanding of APC and DRG reimbursement.
Requires knowledge of current computer technology, including the use of computers; knowledge and proficiency with associated software, including Excel and Word
Requires flexibility and adaptability to frequently changing processes
Skilled in establishing and maintaining effective working relationships with co-workers and clients
Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency
Detail-oriented with ability to focus for extended periods
Ability to work independently, seeking supervision as needed
Ability to communicate professionally, clearly and effectively, verbally and in writing
Ability to meet attendance requirements to effectively fulfill all functions of the position
Ability to independently follow through on assigned tasks, without prompting
Ability to prioritize effectively
Ability to multitask
Physical Demands & Requirements:
Communicates by way of the telephone with participants, customers, vendors and staff
Operates a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
Remains stationary for extended periods of time
Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
Frequent, repetitive use of hands/fingers entering information on a keyboard
This job operates in a home office environment with a conversational noise level.
No substantial exposure to adverse environmental conditions is expected
Moderate pressure to meet scheduled appointments and deadlines
Potential for occasional verbal aggression by clients and vendors
***This is a remote position. Adequate internet speeds and a suitable home-office environment are required for this position. All new team members will be bound by the “Teleworking Agreement’ and must continually meet the terms of the agreement to maintain remote work status.
The Company is proud to be an equal opportunity employer. All qualified applicants will receive consideration without regard to ancestry or national origin, race or color, religion or creed, age, disability, AIDS/HIV, gender, marital or family status, pregnancy, childbirth or related medical conditions, genetic information, military service, protected caregiver obligations, sexual orientation, protected financial status or other classification protected by applicable law.
- Pay Type Hourly
- Travel Required No
- Telecommute % 100
- Required Education High School
- St. Louis, MO, USA