Senior Claims Examiner

📋 Description

• • Audit medical and dental claims for accuracy in data, payments, contract interpretation, and compliance with established policies and procedures for Banner Health’s Risk, Health, and Dental Plans.
• • Research and process claims adjustments including reconsiderations, refunds, voids, and special projects to ensure proper adjudication and payment accuracy.
• • Conduct random and targeted claim audits to verify adherence to compliance standards across Medicare, AHCCCS, Self-Funded, and Commercial insurance plans.
• • Manage end-to-end claims administration workflow to meet Plan requirements and regulatory timelines, ensuring timely resolution of claims across multiple benefit programs.
• • Serve as the primary resolution specialist for escalated and complex claims issues, collaborating with internal departments such as Customer Service, Provider Relations, Networks, Finance, and Medical Management.
• • Respond to inquiries from internal and external clients regarding claim status, payment discrepancies, and benefit interpretations, maintaining accurate system records for auditing purposes.
• • Develop and generate detailed reports to track claims trends, identify quality improvement opportunities, and monitor workflow efficiencies for training and operational purposes.
• • Support mass adjustment initiatives by analyzing large volumes of claims data and implementing corrective actions in alignment with policy updates.
• • Act as a subject matter expert on claims processing guidelines, providing in-service training and guidance to staff on changes to Medicare, AHCCCS, CPT, HCPCS, and ICD-9/ICD-10 coding standards.
• • Work independently within defined processes while maintaining high accuracy and attention to detail in a fast-paced, remote environment.
• • Review and respond to emails related to claim encounters, vendor communications, and special project assignments to ensure continuous operational flow.
• • Maintain complete and organized documentation of all claim support files for internal and external audit readiness.
• • Ensure compliance with all federal and state regulations governing claims processing under Medicare, Medicaid (AHCCCS), and commercial insurance contracts.