Claims Examiner, Sr. jobs in Orlando, FL

About us

Headquartered in Maitland, FL with our brokerage and marketing office in St. Petersburg, Anchor Benefit Consulting represents small to mid-size employers with their health plan designs and consumer driven products. Known for our boutique style services and plans, Anchor is committed to helping employers offer competitive, valuable health benefits to their most valued assets, their employees.

Anchor Benefit is a third-party administrator (TPA), retained by employers, to pay claims and assist with other plan administration and compliance.

Anchor Benefit is not an insurance company. The employer pays for the plan expenses not paid by plan participants.

Job Description

CLAIMS EXAMINER/AUDITOR

Position Summary

Positions in this function are responsible for claims evaluation, adjudication and customer service in accordance with agreed quality and production standards. Processes claims in a timely manner and complies with industry fair claims practices and applicable federal regulations concerning the processing of claims. Authorizes the appropriate payment or refers to claims manager for further review. Conducts data entry and re-work; analyzes and identifies trends and provides reports as necessary. Responsible for ensuring a high level of customer service and maximizing productivity while cultivating customer relationships.

Primary Responsibilities:

• Examine, review, and process claims for accuracy, completeness and eligibility.
• Interpret claim forms: CMS 1500, UB-04, dental and vision claims.
• Analyze claims costs and appropriate payment in accordance with plan terms.
• Resolve claims through approval or denial.
• Conduct routine and complex claims audits and provide feedback.
• Document findings, approvals, and recommendations.
• Contact provider/billing offices when necessary for billing discrepancies/overpayments.
• Analyze trends, successes, and issues in claims process.
• Coordinate benefits.
• Consistently meet established productivity standards.
• Respond to claim appeals and/or issues from plan members and/or providers.
• Recognize and properly address coverage issues, potential fraud, and subrogation potential.
• Claims research for new CMS and Medicaid guidelines.
• Maintain and support quality customer service for plan members/healthcare providers (verification of eligibility and benefits, etc.).
• Coordinate with benefit/customer service specialists and other administrative support personnel.
• Recommend desirable workflow and business rules refinements to improve the company claims process, when applicable.
• Perform reports on claims analysis as necessary.
• Maintains good, professional working relationship with superiors and peers.
• Catalog and record job files for storage.
• Perform other duties as assigned.

Required Qualifications:

• High school graduate, some college preferred.
• Minimum of 3 years’ as a claims examiner/auditor health care claims (HCFA 1500, UB-04).
• Minimum of 3 years’ experience in processing dental/vision, FSA, section 105 claims.
• Minimum of 2 years’ experience in customer service.

• Extensive knowledge of claims and auditing process.
• Knowledge of and adherence to accepted standards of health policy provisions and guidelines.
• Possess strong verbal, written, and interpersonal communications skills.
• Attention to detail.
• Knowledge of medical coding systems and terminology.
• Computer software proficiency with Microsoft Office, Excel, PowerPoint, and Access, which includes the ability to learn new system applications.
• Strong organizational skills.
• Ability to multi-task and prioritize.
• Strong adherence to confidentiality of claims information.

Job Specifications

Knowledge, skills and abilities required for competent performance in the job:

• Comprehensive knowledge of medical terminology, medical coding, COB, (CPT, ICD-10, HCPCS)
• Ability to recognize HCFA vs UB-04 claims.
• Process 150 claims daily/8-hour shift.
• Consistently meet 98% accuracy in paid and denied claims.
• Computer literate. Strong skills in MS Word and Excel, which includes the ability to learn new and complex computer system applications, if necessary;
• Excellent reading comprehension and organizational skills
• Excellent analytical, problem solving and decision-making skills and ability to deal professionally with people in stressful situations.
• Ability to maintain confidentiality and interact in a positive and constructive manner with peers.
• Excellent attendance.
• Compliance with HIPAA regulations.
• Team player and self-motivated.
• Applicable knowledge of Affordable Care Act.

Other Duties: Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

Work Environment

• Performs duties in an office environment consisting of computer equipment, phones, and background noise.

• Extended periods of sitting at a computer and use of hands/fingers across keyboard or mouse.
• Occasionally required to lift, push, pull, twist or otherwise handle items of 10- 25 pounds.
• Computer and peripherals, standard and customized software, and usual office machines.

Additional Job Information:

Employment Type: Full-Time; Regular
Department: Claims
Schedule: Full-Time (40 hours/week)
Pay Level: $19 - $25
Job Level: Individual Contributor
Location: Maitland, FL
Shift: Monday through Friday; 8:00am – 5:00pm
Travel: None
Telecommuter: Flexible
Overtime Status: Non-Exempt
Start Date: Immediate
Relocation Provided: No
Language Preference: Bilingual (English/Spanish)

Benefit Conditions:

• Waiting period may apply
• Only full-time employees eligible

COVID-19 Precaution(s):

• Remote interview process
• Personal protective equipment provided or required
• Social distancing guidelines in place
• Virtual meetings
• Sanitizing, disinfecting, or cleaning procedures in place

Work Remotely

• Yes

Job Type: Full-time

Pay: $39,520.00 - $52,000.00 per year

Benefits:

• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• In-person
• Office

Education:

• High school or equivalent (Preferred)

Experience:

• Claims examiner: 3 years (Required)

Language:

• Spanish (Preferred)

Work Location: In person