Medical Claims Examiner

SUMMARY
This position is intended to provide billing and claims management support to Alivi Specialty Networks
and Business Process Outsourcing (BPO) Services. The Medical Claims Examiner will ensure all claims
received comply with all health plan, regulatory, contractual, compliance, and Alivi billing guidelines
and processes.

DUTIES & RESPONSIBILITIES

• Responsible for accurate and timely adjudication of professional and institutional claims

according to state and federal regulations.

• Demonstrates knowledge of insurance regulations and policies, payment policies/guidelines

and the ability to communicate and work with payers to get claims resolved and paid
accurately.

• Demonstrate skills in problem solving, benefit plan, and provider contract Interpretation.
• Analyzes, processes, researches, adjusts, and adjudicates claims with the use of accurate

procedure/revenue and ICD-10 Codes, under the correct provider contract and member
benefits.

• Responds to provider disputes in a timely and accurate manner.
• Research provider disputes to ensure appropriate claims dispute resolutions.
• Works Directly with Clinical Review Board and Network Operations Team to resolve complex

issues or disputes.

• Adjudicates claims that have been overturned by the Clinical Review Board or Network

Operations Team.

• Generates written correspondence to members, providers, and regulatory agencies.
• Responds and assists other departments with complex issues for resolution or affirmation of

previously processed claims and existing guidelines.

• Determines and processes overpayments (provider refunds) and reimbursement requests

according to specific state and/or federal guidelines or as agreed to in provider contract.

• Determines and processes underpayments (internal errors) and provider reimbursement

requests, which may involve the use of spreadsheet research and correspondence.

• Maintains the department’s claim edit rules and processing claims according to client specific

verification of eligibility, interpretation of program benefits and provider contracts to include
manual pricing.

• Identifies trends in claims flows and suggests process improvements.
• Assist in preparation with Claims Audits.
• This position description identifies the responsibilities and tasks typically associated with the

performance of the position.

REQUIREMENTS

• High School diploma or equivalent.
• 3 years’ work experience in claims operations environment in the healthcare insurance

processing Medicare.

• Hands-on working experience processing medical claims in insurance industry.• Knowledge of Medicare Fee Schedule and alternative payment methods (global, cap, flat

fees).

• Self-starter, ability to work independently and in a team environment.
• Strategic, analytical, process oriented and must have critical thinking skills.
• Excellent written and verbal communication skills.
• Ability to manage multiple priorities.
• Excellent problem-solving skills, good follow-up abilities and willingness to be flexible and

adaptable to changing priorities.

• Works well under pressure.
• Proficient with Excel, PowerPoint, Word & Outlook.
• Knowledge of medical terminology and comprehension in the usage of CPT Codes, ICD-10

Codes and Revenue Codes.

• Knowledge of Correct Coding (CCI) Edits.
• Experience in gathering all necessary documentation in preparation of Delegation Audits.
• Detailed knowledge of electronic billing processes universal billing forms.
• Knowledge of CMS/ACHA Regulations is desirable.
• Previous Experience using Health Suite is desirable.
• Certified Professional Coder (CPC) is desirable.