Examiner, Claims

JOB DESCRIPTION Job Summary Provides support for claims examination activities including evaluation of adjudication of claims to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors.

Essential Job Duties

Evaluates the adjudication of claims using standard principles, and state-specific regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and claims processing errors.

• Manages a caseload of claims - procures all medical records and statements that support the claim.
• Makes recommendations for further investigation and/or resolution of claims.