Healthcare Claims Examiner

🔥 1 hour ago

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $50k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Claims Specialist

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Allied Benefit Systems

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1980

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Allied Benefit Systems is a national healthcare solutions company that provides health plan administration, care and cost management, provider network services, and data analytics to employers, members, and benefits consultants. The company focuses on reducing healthcare costs, optimizing plan performance, and improving member experience through administrative services, analytics & insights, and customizable provider networks.

📋 Description

• Independently review and analyze health care claims for cost reasonableness, medically unnecessary treatment, and fraud • Determine whether claims are covered and the level of benefits payable to providers • Contact providers to negotiate discounts • Log negotiated claims in Access and create weekly summary reports • Review and understand customized client plan terms and conditions • Request, review, and analyze physician notes, hospital records, and police reports • Consult with entities providing additional claim evaluation • Process claims in the QicLink System • Review, analyze, and add notes to QicLink System • Document information in QicLink System, alliedbenefit.com, and other available systems • Review billed procedure and diagnosis codes for billing irregularities and inconsistencies • Analyze procedure and diagnosis codes for medical necessity • Authorize payment, partial payment, or denial based on investigation and analysis • Review Suspended Claim Reports and follow up on open issues • Assist and support other team members as needed • Attend required continuing education, including HIPAA training • Perform other assigned duties

🎯 Requirements

• High School Diploma required; college and advanced degrees preferred • Equivalent work experience accepted in lieu of a high school diploma • Minimum of 5 years of medical claims analysis experience, including dental and vision claims analysis • Strong analytical skills • Knowledge of computer systems • Knowledge of CPT and ICD-9 coding terminology • Continuing education in all areas affecting group health and welfare plans • Understanding of customized group health plan terms and conditions • Knowledge of HIPAA, HITECH, and applicable privacy and security laws • Cable broadband or fiber optic internet service with at least 100Mbps download and 25Mbps upload • Ability to work extended periods sitting and performing computer work

🏖️ Benefits

• Medical Insurance • Dental Insurance • Vision Insurance • Life Insurance • Disability Insurance • Generous Paid Time Off • Tuition Reimbursement • Employee Assistance Program (EAP) • Technology Stipend • Remote work flexibility • Continuing education classes and HIPAA training

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