CLAIMS EXAMINER I-CMO
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Receives claims for CMO members and processes claims according to CMO, health plan, State and Federal policies and guidelines. Maintains production and quality goals established for the department. This includes verification of member and provider eligibility, availability of benefits and application of the correct fees, co-pays and coinsurance amounts. The examiner will process a determined number of claims per day, with a dollar limit of $5000 for HCFA and $25000 for UB92. Evaluates and examines claims pended by the system due to contractual and/or payment discrepancies. Analyze claims received against benefits as they apply to all contracted health plans to make a payment determination. Assure that claims are paid, pended or denied according to department, state and health plan policies, procedures, and fee schedules. Reviews descriptions of services on claims to determine validity of charges of the presence of errors. Interact with other CMO areas to resolve eligibility and provider files issues. Performs other related duties, i.e., maintaining individual production counts, updating manuals and reference materials, attending all refresher training seminars
Education, Training & Experience:
- NYS Claims Adjuster's License - If not licensed; A period of three months (probation) is granted to obtain the license.
- High School Diploma or equivalency
- Knowledge of ICD-10, CPT-4, HCPCS coding.
- Medical Terminology or equivalent experience in the medical billing field.
- Prior computer data entry in Windows environment.
Department: Administration Bargaining Unit: 1199 Campus: YONKERS Employment Status: Regular Full-Time Address: 100 Corporate Drive, Yonkers
Shift: Day Scheduled Hours: 8 AM-4:30 PM Req ID: 170944
Montefiore is an equal employment opportunity employer. Montefiore will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.
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