Claims Examiner
Seven Feathers Casino Resort - Roseburg, OR

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POSITION PURPOSE:
Responsible for procedures relating to claims processing. To be able to communicate with members and health care professionals, provide customer service to members and providers of Nesika Health Group,

ESSENTIAL FUNCTIONS:
Processing all claims for payment/denial

Determine pre-existing conditions

Send out pre-existing inquires to members and providers

Obtaining accident information/TPR information

Electronic claims processing/Re-pricing as necessary

Verify insurance eligibility to providers

Relay benefit information to members and providers

Assisting Lead claims Analyst with completing provider 1099’s as necessary.

QUALIFICATION STANDARDS:
H.S. Diploma (or equivalent) required.

Four (4) years relevant claims experience OR Bachelors degree & two (2) years relevant experience

Ability to work independently with minimal supervision

Maintain integrity of confidential files/information

Good written and oral communication skills.

General knowledge of COB- coordination of benefits

HIPAA regulations and compliance

Medicare regulations and compliance

Ability to work within Databases

General knowledge of claims adjudication

Knowledge of medical terminology.

Knowledge of ICD-9, CPT, and HCPCS coding

Knowledge of Microsoft Word, Excel and Outlook

Ability to read and interpret general business correspondence, procedure manuals, and specific plan documents.

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.

Excellent keyboarding skills.

Ability to perform basic math functions – addition, subtraction, multiplication, and division.

Ability to work and communicate effectively in a team environment.

Ability to work under pressure.

Ability to work in an environment with fluctuating workloads.

Assistance/Back-up for other office staff that is required due to vacations, sick leave, etc.

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