Healthfirst

The Senior Claims Examiner is responsible for the investigation, determination and reporting of claims processing thru auditing of normal business processes as well as handling second level appeal requests. The incumbent will audit, conduct root cause analysis, handle processing of determinations, track and trend findings. The Senior Claims Examiner will also assist management with measures to ensure processing and payment accuracy; and will ensure adherence to departmental, corporate and governmental policies and regulations.

Duties and Responsibilities:

• Reviewing and investigating claims and encounters for medical, facility, pharmacy, dental and vision services including contractual provisions, authorizations and Healthfirst Policy and Procedure.
• Subsequent auditing and handling of specific claims and appeal requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.
• Identifying defects and improving departmental performance by supporting quality, operational efficiency, and production goals.
• Reporting and presenting preliminary findings based on trending and interpretation.
• Trending and comparing analyses against departmental and corporate standards.
• Assist with developing and participating in effective training and documentation.
• Soliciting and coordinating required information between Management staff and team members to complete daily assignments.   
• Examining and Processing of Claims.   
• Working on multiple audits, appeals or other ad hoc projects.
• Additional duties as assigned.
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  Minimum Qualifications:
• High School Diploma or GED from an accredited institution
• Experience identifying root cause claims adjudication process failures and ability to quantify departmental impact.
• Experience with the investigation, determination, and reporting of claims processes.
• Experience working within Excel spreadsheets which includes formatting formulas and filtering results.  As the Senior Claims Examiner you will be working on multiple audits, appeals or other ad hoc projects.
• Experience handling Personal Health Information (PHI) in a professional manner.
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  Preferred Qualifications:
• Associate degree or higher.
• Experience in an Auditing capacity where you have conducted root cause analysis.
• Ability to work analytically and provide creative ideas for problem solving.
• Ability and willingness to handle increasing workload and responsibility.
• Willingness and ability to learn and evaluate new information, both technical and procedural.
• Excellent written and oral communication and interpersonal skills with the ability to demonstrate professionalism and diplomacy.
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  Compliance & Regulatory Responsibilities: N/A
  License/Certification: NA

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $56,000 - $74,880

• All Other Locations (within approved locations): $48,600 - $70,720

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.