The Claims Examiner II is responsible for analyzing and adjudication of medical claims as it relates to managed care. Performs payment reconciliations and/or adjustments related to retroactive contract rate and fee schedule changes. May resolve claims payment issues as presented through the Provider Dispute Resolution (PDR) process or from claims incidents/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payment. Collaborates with other departments and/or providers in the successful resolution of claims-related issues. Minimum Requirements: HS Diploma or GED, Minimum of 3 years of Claims Processing experience in a managed care environment. Experience in reading and interpreting DOFRs and Contracts is required. Experience in reading CMS-1500 and UB-04 forms is required.
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