Health Claims Examiner

**NO EXPERIENCE NECESSARY- WE WILL TRAIN**

Do you want a career where you can make a difference? Allegiance is a growing company with hometown values that is looking for dynamic candidates to join the team! A positive, team-oriented environment is provided with opportunities for advancement.

Allegiance offers full-time positions with evenings, weekends, and holidays off and a multi-faceted benefits package.

We pride ourselves in having a reputation for top-notch customer service. Make a difference. Start your career with Allegiance today!

POSITION RESPONSIBILITIES:
The Claims Examiner is responsible for the accurate and timely processing of medical, dental, vision and pharmacy claims. The incumbent is expected to provide courteous and prompt responses to customer inquiries.

The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position.

ESSENTIAL JOB FUNCTIONS:

Essential job functions include the following. Other functions may be assigned as business conditions change.

-Verifies the accuracy and receipt of all required documentation for each claim submitted.

-Collaborates with providers, plan participants, other claims payers, or any other party necessary to obtain information necessary to accurately process a claim.

-Analyzes information necessary for processing. This includes, but is not limited to, general participant and provider information, managed care affiliation, diagnosis codes, dates, place, type of service, procedure codes, and charges.

-Assures that the system processes the claim correctly and determines payment according to the plan as written.

-Word-processes correspondence to plan participants and providers in reference to pre-determinations and in response to basic benefit questions.

-Answers telephone calls from plan participants, group contacts, and customer service representatives pertaining to benefits and claims inquiries.

-Resolves problematic claims with the assistance of the Team Leader, Claims Manager and/or the Director of Claims.

-Assigns critically ill patients to large case management. Assists the case manager with direct negotiation and the efficient use of benefits.

-Assists other examiners as needed due to workload requirements, including assigned back-up when examiners are absent.

-Aids the Team Leader and/or the Claims Manager in the resolution of claim appeals and disputes by providing documentation for review.

-Researches, calculates and requests refunds when necessary.

-Contributes to the daily workflow with regular and punctual attendance.

-Thoroughly researches and completes renewal reports in a timely manner in consultation with the Marketing Department.

-Process eligible claims on groups before the end of their stoploss contract renewal period.

-Assists the Legal Department with subrogation claims as necessary.

-Attends various group meetings as required.

-Assists with audits as needed

-Assists with plan benefit set-up and changes as needed.


NON-ESSENTIAL JOB FUNCTIONS:
Performs related or other assigned duties as required or directed


SUPERVISION EXERCISED:
None.

PHYSICAL WORKING CONDITIONS:
Physical requirements are representative of those that must be met to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Sitting 80%

Reaching Some

Standing 10%

Manual Dexterity High

Walking 10%

Telephone Yes

Kneeling Some

Computer Screen High (visual acuity corrected to 20/30)

Bending Some

Lifting up to 30 pounds

JOB SPECIFICATIONS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements lis