Now Hiring - Providence Risk and Insurance Services Inc - EXMNR in San Antonio, TX

Full description of the position

Group Health Claims Examiner Posting will remain active until positions are filled EOE Summary To process claims in relation to individual client Group Health Plans and liability exposures in accordance with established claim handling guidelines and answer benefit questions posed by clients, claimants and providers. The statements contained herein reflect general details to describe the key functions of this job, the level of knowledge and skill typically required, but should not be considered an all-inclusive listing of work requirements. Individuals may perform other duties as assigned, including work in other functional areas to cover absences, to equalize peak work periods or otherwise to balance the workload Essential Functions: Maintain punctuality and attendance as outlined in the Time and Attendance Policy Analyze group health claim to determine: Eligibility of claimant-employee, spouse, dependent, child or incapacitated child Completeness of claim form and attending physician statement Eligibility of claim, (i.e. medical necessity of services, third party liability, occupational health, other insurance). Data entry for adjudicating claim based on the plan document Production standard of 5 days or less turn-around time Answer incoming calls from members and providers Verification of benefits to include eligibility Check tracers Claim status inquiries Adjustment of claims Precertification approval Referrals to case management Flexible Spending Accounting balance inquiries Claims editing vendor PHX extractions / uploads PPO Repricing Primary contact for Broker and Clients Account coordinator assigned to specific group accounts Setup benefit schedule through IVR Primary contact for claim issues Clerical support tasks as assigned Verification with networks regarding repricing & eligibility Additional duties or projects as assigned by management Example of additional essential functions that may be assigned: Perform system credit functions of refunds, voids and stop-payments as needed PBM Pharmacy Benefit Management Extractions / upload accumulators Competencies To perform the job successfully, an individual should demonstrate the following competencies: Adaptability Adapts to changes in the work environment; manages competing demands; able to deal with frequent change, delays, or unexpected events; changes approach or method to best fit the situation; Achievement Focus Measures self against standard of excellence; Recognizes and acts on opportunities Analytical Collects and researches data; uses intuition and experience to complement data Attendance and Punctuality Is consistently at work and on time; ensures work responsibilities are covered when absent; adheres to Providences time and attendance policy Business Acumen understands business implication of decisions Communications Expresses ideas and thoughts verbally and in written form; must have good command of the English language, oral and written; exhibits good listening and comprehension; keeps others adequately informed; selects and uses appropriate communication methods Conflict Resolution Encourages open communications; confronts difficult situations; maintains objectivity; keeps emotions under control; uses negotiation skills to resolve conflict Continuous Learning Seeks feedback to improve performance; Pursues training and development opportunities; shares expertise with others Cooperation Establishes and maintains effective relations; exhibits tack and consideration; offers assistance and support to co-workers; works cooperatively in group situations; works actively to resolve conflicts Cost Consciousness conserves organizational resources Customer Service Manages difficult or emotional customer situations; responds promptly to customer needs; responds to requests for service and assistance, meets commitments Dependability Follows instructions, responds to management direction; takes responsibility for own actions; completes tasks on time and/or notifies supervisor or manager if needs assistance prior to deadline being missed Diversity Shows respect and sensitivity for differences, promotes a harassment-free environment Ethics Treats people with respect, keeps commitments; inspires the trust of others; works with integrity and principles; upholds organizational values Impact and Influence Pursues and wins support for ideas; displays ability to influence key decision-makers; achieves win-win outcomes; uses authority appropriately to accomplish goals; addresses divergent opinions Initiative Volunteers readily as workload permits; asks for and offers help when needed Job Knowledge Competent in required job skills and knowledge; exhibits ability to learn and apply new skills; requires minimal supervision; displays understanding of how job related to others; uses resources effectively Judgment Displays willingness to make decisions; exhibits sound and accurate judgment; supports and explains reasoning for decisions; includes appropriate people in decision-making process; makes timely decisions Oral Communication Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions; demonstrates group presentation skills; participates in meetings. Organizational Support Follows policies and procedures; supports organizational goals and values Personal Appearance adheres to Providences Personal Appearance Policy; keeps self well groomed Planning and Organizing Prioritizes and plans work activities; uses time efficiently; plans for additional resources; sets goals and objectives; develops realistic action plans Problem Solving Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with emotional topics Quality Demonstrates accuracy and thoroughness; looks for ways to improve and promote quality; applies feedback to improve performance; monitors own work to ensure quality Quantity completes work in timely manner; meets productivity standards; ability to work in a fast-paced, multitasked environment; able to efficiently handle workload within set deadlines Strategic Thinking Supports strategies to achieve organizational goals Teamwork Balances team and individual responsibilities; exhibits objective and openness to others views; gives and welcomes feedback in a respectful, professional manner; contributes to building team spirit; puts success of team above own interests; able to build morale and group commitments to goals and objectives; supports everyones efforts to succeed. Use of Technology demonstrates required skills; adapts to new technologies; ability to adapt to and work in a paperless environment Written Communication writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; presents numerical data effectively; able to read and interpret written information. Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education and Experience High school diploma or general education diploma (GED) Two plus years of claims experience preferred Strong knowledge Medical Terminology Strong knowledge of current ACA guidelines Language Skills Ability to read, analyze and interpret plans, client protocols, medical documentation and government regulations. Ability to write emails, reports, business correspondence and document files clearly. Ability to effectively present information and respond to questions from groups of managers, clients and customers. Mathematical Skills Ability to add, subtract, multiply and divide in all units of measure using whole numbers, common fractions and decimals. Reasoning Ability Ability to define problems, collect data, establish facts and draw valid conclusions. Ability to interpret a variety of instructions furnished in written, oral, diagram or scheduled form. Computer Skills Ability to learn and utilize industry specific computer software Knowledge of Outlook Basic knowledge of Microsoft Word and Excel Type 32 WPM Work Conditions The demands described are representative of those that must be met by staff members to successfully perform the essential functions of this job. Reasonable accommodations may be made for individuals with disabilities to perform essential functions. May work more than 40 hours per week Monday Friday, 8.5 hour, day shift, one hour lunch; may work weekends and/or evenings based on business needs, with prior manager approval Ability to operate computer and other office equipment such as keyboard, phone, copy machine, etc. Must be able to remain in stationary position (excluding breaks/lunch) The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc. Able to perform job in an environment with low to moderate noise and/or level of distractions Occasionally move up to 10 pounds Job Type: Full-time Pay: $20.00 per hour Expected hours: 37.5 40 per week Education: High school or equivalent (Required) Experience: claims examiner: 1 year (Required)