Medicare Supplement Claims Examiner

Job Summary:

The Medicare Supplement Claims Examiner is a multifaceted role that combines the accurate and efficient processing of Medicare Supplement claims while upholding payment integrity and preventing fraud, waste, and abuse. The Medicare Supplement Claims Examiner will review claims for signs of fraudulent activity or improper billing practices, taking appropriate action to investigate and resolve these issues in collaboration with our internal stakeholders. In addition to claims processing and fraud prevention, the Medicare Supplement Claims Examiner will play a crucial role in identifying opportunities for cost savings and efficiency improvements within the claims processing system. Emphasis will be placed on ensuring all claims are processed in strict adherence to CMS guidelines, while providing expert guidance and support to the Customer Service Representative team. Dedication to accuracy, attention to detail and commitment to ethical standards in healthcare billing is essential to success in this role.

Key Responsibilities:

Claim Adjudication and Analysis:

o Conduct thorough reviews of submitted claims, verifying the accuracy and completeness of the information provided. o Analyze claims against policy terms, Medicare guidelines, and company procedures to determine coverage eligibility and evaluate the medical necessity and appropriateness of services rendered. o Make decisions on whether to approve, deny, or request additional information for claims.

Payment Integrity:

o Ensure the integrity of payment processes by verifying that all claims are processed accurately according to policy terms and regulatory guidelines. o Monitor any irregularities in billing practices and take corrective action as necessary to prevent payment errors and overpayments. o Implement best practices for accurate reimbursement. Fraud, Waste and Abuse (FWA)

Prevention:

Review claims for potential signs of fraudulent activity, waste, or abuse. o Investigate suspicious claims and collaborate with internal stakeholders to address and report any confirmed cases. Contribute strategies to prevent FWA and maintain compliance with industry standards.

Benefit Determination:

o Evaluate medical necessity and appropriateness of services rendered, utilizing clinical knowledge and Medicare regulations. o Ensure the claims are adjudicated correctly according to the policyholder's plan and regulatory guidelines. o Communicate benefit determinations clearly and accurately to relevant stakeholders.

Communication and Coordination:

o Liaise with Customer Service Team Lead/Supervisor to coordinate with policyholders, providers, and Medicare Administrative Contractors (MACs) to obtain necessary documentation and clarify discrepancies. o Provide clear and concise information to stakeholders regarding claim status, coverage determinations and payment details.

Compliance and Guidelines Adherence:

o Stay informed about CMS guidelines, including updates to the Medicare Benefit Policy Manual, particularly regarding payments for non-participating providers. o Ensure all claims are processed in strict compliance with these guidelines.

Document and Reporting:

o Maintain detailed records of all claims processed, decisions made, and communication with stakeholders. o Contribute to reviews for management, analyzing claims data to identify trends, discrepancies, and areas for improvement.

Customer Service Support and Training:

o Serve as a resource for guidance and support to Customer Service Representatives to ensure high standards of service and efficiency. o Resolve issues related to denied or disputed claims, including handling appeals and reprocessing claims, as necessary.

Continuous Improvement:

o Participate in continuous improvement initiatives to enhance efficiency, accuracy, and policyholder satisfaction of the claim process. o Contribute ideas and feedback to improve claims processing procedures and systems.

Qualifications:

Experience:

Minimum 2-4 years of experience in Medicare Supplement claims processing or related field.

Knowledge:

Comprehensive understanding of Medicare Supplement plans, 837 EDI transactions, DME claims, and relevant regulations.

Education:

Bachelor's degree in healthcare administration, business or a related field or equivalent work experience.

Certifications:

Relevant certifications such as Certified Professional Coder (CPC), or Certified Medical Reimbursement Specialist (CMRS) are a plus.

Skills:



Analytical Skills:

Strong analytical and problem-solving skills to evaluate claims and identify discrepancies.  Attention to

Detail:

Exceptional attention to detail to ensure accuracy in claims processing and documentation. 

Regulatory Knowledge:

In-depth knowledge of correct coding and CMS claim adjudication guidelines. 

Technical Proficiency:

Proficiency in using Microsoft Office Suite, claims processing and documentation applications. 

Communication:

Excellent verbal and written communication skills, with the ability to interact effectively with internal and external stakeholders. 

Integrity:

Strong commitment to ethical standards in healthcare billing and fraud prevention. 

Time Management:

Ability to handle multiple tasks efficiently, prioritize work, and manage time efficiently in a high-volume environment. 

Adaptability:

Flexibility to adapt to changing industry trends, company policies and policyholder needs. 

Collaboration:

Ability to work collaboratively with internal stakeholders for fraud prevention. Work Environment /

Physical Requirements:

The work environment is a standard office setting with typical office equipment. This role involves professional collaboration with colleagues and clients. Responsibilities may involve extended periods of sitting, occasional walking between departments or meeting rooms, and periodic standing, reaching, stooping, and lifting office items weighing up to 25 pounds.