Job Description

The Claims Examiner II requires the ability to work in a high volume claims environment including daily processing of various types of claims. This role consistently meets production and quality standards and is responsible for reviewing, correcting and releasing claims in the claim adjudication system.

ESSENTIAL FUNCTIONS:

• Processes all claim submissions for adjudication and payment.
• Meets required performance guarantee deadlines, company objectives and production and quality standards.
• Investigates open authorizations and questionable claims and/or services.
• Researches claim payment discrepancies.
• Supports the Contact Center regarding plan benefits or doctor questions.
• Adheres to privacy and confidential and proprietary company policies and procedures (i.e. HIPAA).
• Participates in any/all training and educational activities necessary to fulfill at least the minimum requirements as specified within your departmental goals. This is in addition to, the completion of any activities necessary for the maintenance of professional affiliations or organizational requirements.
• Diligently maintains the cleanliness of all equipment, workstations and the overall facility on a daily basis.
• As required by changing business needs, completes additional responsibilities as assigned.

·       Perform data entry and coding.

·       Other duties as assigned

EDUCATION AND EXPERIENCE:

• High School Diploma/GED or equivalent
• Associate Degree in Business Administration or equivalent preferred
• Three plus years claims processing (medical, dental and/or vision) is required
• Knowledge of provider reimbursements and experience in the vision insurance industry would be preferred

COMPETENCIES:

·       Excellent interpersonal skills

·       Understanding of the Healthcare industry

·       Timely and thorough problem resolution skills

·       Detail oriented

·       Strong organizational skills and the ability to be resourceful in problem solving.

·       Strong communication skills - written and verbal

·       Strong analytical abilities and demonstrated use of good judgment

·       Ability to work independently utilizing company established processes

·       Strong execution and follow-up skills

·       Ability to meet deadlines

·       Strong computer skills including Excel and Microsoft Word

·       Good working knowledge of claims adjudication systems

·       Goal oriented with ability to meet production standards

ESSENTIAL RESPONSIBILITIES RELATED TO PHYSICAL DEMANDS/WORK ENVIRONMENT:

The physical demands described here are representative of those that must be met by an associate to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. While performing the duties of this job, the associate is required to stand, use hands and fingers to handle, feel, pick or pinch, and talk or hear most of the time.  The associate is occasionally required to stand, walk, and reach with hands and arms.   The associate must frequently lift and/or move up to 20 pounds.  The noise level in this location is moderate (use of computers, printers and machines). Ability and willingness to travel as required.

HIPAA & SECURITY REQUIREMENTS

All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures. As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times.  As a result, Associates must explicitly adhere to all data security guidelines established within the Company’s Privacy & Security Training Program.

Company Description

Versant Health bringing you Davis Vision and Superior Vision is a leading provider of vision and eye health solutions. We offer a full spectrum of services in the vision care marketplace. Our mission is very real to our members: we help them enjoy the wonders of sight through healthy eyes and vision. What you do as a Versant Health Associate matters. 37 million Americans count on us to provide access to annual eye exams and corrective eyewear. We are here to change the face of vision care, and together we will make this happen.