Medical Claims Examiner

Next Step Systems - Tucson, AZ

Full-time

Onsite - Tucson, AZ

Professional, Scientific, and Technical Services

About the position

The Medical Claims Examiner is responsible for processing and adjudicating medical and inpatient claims from various provider types and lines of business. This role involves reviewing and resolving rejected or denied claims, conducting research and analysis, and ensuring compliance with billing and claims processing policies. The position requires strong analytical skills and the ability to maximize reimbursement while providing education and support to both internal teams and customers.

Responsibilities

• Submit claims and encounters in a timely manner.
• Review and resolve rejected, pended, and/or denied claims within expected timeframes.
• Coordinate claim adjustments with the customer.
• Identify revenue cycle issues and implement solutions to improve systems and processes.
• Respond to calls on claims issues and provide information and resolution in a timely manner.
• Provide education and technical support to Claims Examiners and customers regarding claims related issues through online training and in-person training.
• Produce scheduled reports for in-house and customers.
• Prepare written inter-departmental and external correspondence.
• Develop and publish formal written guidance for customers to process claims.
• Analyze encounter-processing data using statistical methodologies.
• Update and maintain electronic billing manual and distribute updates as directed.
• Compare business operations and coordinate technical analysis support for upcoming collection of accounts.

Requirements

• Experience with ICD-10, CPT, HCPCS, In-Patient Billing, Rejections, Accounts Receivable (A/R), Account Reconciliation, and Prior Authorizations.
• Experience with Medicare/Medicaid Billing and Claims.
• High School diploma or GED plus 5 years of full-time data entry experience in claims processing, accounting, analysis, and adjudication of Medical and/or Behavioral environment.
• Knowledge of HIPAA regulations.
• Knowledge of Microsoft Excel and 10-key by touch.
• Experience working with Electronic Health Records system(s).
• Ability to translate customer needs to technical and/or business process solutions.
• Strong customer service skills and abilities.
• Exceptional communication skills, including strong customer-facing presentation and facilitation skills.
• Ability to work on multiple projects with strong attention to detail and follow-through skills.
• Experience working in a team-oriented, collaborative environment.
• Strong analytical and problem-solving abilities.