Key Facts

Remote From:

Full time

Senior (5-10 years)

English

Hard Skills

ICD Coding (ICD-9/ICD-10) Medical Insurance Claims CPT Coding Microsoft Access Group Health Insurance Sales Medical Record Management Medical Necessity Fraud Detection Computer Systems Billing +4 more

Other Skills

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Problem Reporting
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Accountability
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Collaboration
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Communication
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Analytical Thinking

Roles & Responsibilities

5+ years of medical claims analysis experience (including dental and vision)
Strong analytical skills
Knowledge of CPT and ICD-9 coding terminology
Continuing education in group health and welfare plans

Requirements:

Independently review and analyze health care claims for reasonableness, medical necessity, and potential fraud, and determine the level of benefits to be paid.
Process claims in the QicLink system, add notes, log activity, and prepare weekly summary reports; review billed codes for billing irregularities and medical necessity.
Contact providers to negotiate discounts and coordinate with other entities for additional claim evaluation; review accompanying documentation (physician notes, hospital records, police reports) as needed.
Authorize payment, partial payment, or denial based on investigation, and maintain compliance with privacy/security laws (HIPAA/HITECH); document all information in applicable systems; assist team members as needed.

Allied Benefit Systems, LLC

About Allied Benefit Systems, LLC

Allied is a national healthcare solutions company that works with organizations who choose to take control of their healthcare. We customize employer self-insurance benefits to align with individual choice and organizational need while integrating medical management innovations and cost-control strategies. With healthcare designed for people, employers never have to choose between price and the best-fit insurance products to protect employees and their families. Allied’s philosophy is to create a culture of health for our member organizations and their employees beyond simple, medical health. We integrate administrative services, care solutions and analytics to achieve better clinical, behavioral and social patient outcomes. Allied’s programs and benefit services are designed and structured to infuse value on every front – for employers and HR departments, for plan members and their families, for healthcare providers, and for us. We’re in this together, committed to your future.

Company type: Unicorn

Founded: 2018

Company size: 501 - 1000

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Job description

POSITION SUMMARY
The Claims Examiner is responsible for determining the proper payment (if any) of medical claims by group health plans, based upon specific knowledge and application of each client’s customized plan(s).

ESSENTIAL FUNCTIONS

Independently review and analyze health care claims for: 1) reasonableness of cost; 2) medically unnecessary treatment by physicians and hospitals; and 3) fraud.
Determine whether a health plan provides benefits in connection with the claim submitted and the level of benefits to be paid to the provider.
Contact providers to negotiate discounts.
Log claims negotiated in Access database and create weekly summary reports.
Review and understand the terms and conditions of each clients’ customized plans.
Understand and comply with all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
Request, review and analyze any physician notes, hospital records or police reports.
Consult with other entities who can offer additional evaluation of a claim.
Process claims in the QicLink System.
Review, analyze and add applicable notes to the QicLink System.
Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com.
Review billed procedure and diagnosis codes on claims for billing irregularities.
Analyze claims for billing inconsistencies.
Review and analyze specific procedure and diagnosis codes for medical necessity.
Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
Review Suspended Claim Reports and follow up on open issues.
Assist and support other team members as needed and when requested.
Attend continuing education classes as required, including but not limited to HIPAA training.
Other duties as assigned.

EDUCATION

High School Diploma, College and Advanced Degrees Preferred or equivalent work experience required.

EXPERIENCE AND SKILLS

Must have a minimum of 5 years of medical claims analysis experience (including dental and vision claims analysis).
Strong analytical skills
Knowledge of computer systems and CPT and ICD-9 coding terminology.
Continuing education in all areas affecting group health and welfare plans is required.

POSITION COMPETENCIES

Accountability
Analytical Thinking
Collaboration
Communication
Customer Focus
Functional Expertise
Initiative

PHYSICAL DEMANDS

This is standard desk role requiring extended periods of sitting and computer work.

WORK ENVIRONMENT

Remote

Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive.

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

Compensation is not limited to base salary. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life and Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend.

Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time. All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process. It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role.