MDD Forensic Accountants

Claims Examiner I

MDD Forensic Accountants

full-time

Posted on:

Location Type: Remote

Location: Remote • Pennsylvania • 🇺🇸 United States

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Salary

💰 $20 per hour

Job Level

JuniorMid-Level

About the role

  • Process ongoing long-term care insurance claims for either facility or non-facility processing only
  • Review long-term care invoices, Monthly Verification Forms, caregiver logs and/or Statement of Care forms, and all other claims documentation received to determine continued eligibility and proper payment amount
  • Determine whether documentation substantiates that the policyholder continues to meet the level of care and services contained in the policy and approved by the Claim Manager
  • Recognize and refer possible plan of care changes to Claim Management Department based on established Department business rules
  • Accurately document policyholder accounts and correspondence in accordance with established Department processes and procedures
  • Identify and refer possible fraud cases for further investigation
  • Process and document all required diary entries in the CAPS system
  • Maintain compliance with all applicable laws and regulations
  • Meet or exceed all regulatory requirements for processing claims submitted for payments including prompt-pay regulations
  • Process payments in accordance with federal and state laws and Medicare/Medicaid regulations that affect the management and administration of claims
  • Handle confidential information abiding by HIPAA privacy laws
  • Meet or exceed all established minimum expectations/metrics and goals for the position
  • Meet or exceed standards for Productivity and Quality as established for the role
  • Practice excellent oral and written skills to communicate with policyholders or their representatives, and providers by telephone and in writing, as well as with internal co-workers
  • Maintain adherence to all Claim Payment Department processes and procedures
  • Support company values of *We are Dynamic, We are Innovative, We are Connected, and We Succeed Together*.
  • Perform other duties as assigned.

Requirements

  • High school diploma or combination of education and experience
  • Minimum of two years’ experience processing and auditing claims
  • Experience working with medical records and reviewing claims
  • Knowledge of long-term care insurance highly preferred
  • Knowledge of claims processing and regulatory requirements affecting claims processing
  • Possess the ability to perform responsibilities with a sense of urgency demonstrating excellent organizational, attention to detail and customer service skills
  • Ability to work in a team environment with a positive attitude
  • Possess excellent oral/written communication, interpersonal, analytical, and problem-solving skills
  • Knowledge and ability to utilize existing software products including, but not limited to, MS Office products; ability to learn new systems and upgrades in technology utilized
  • Ability to learn and relay knowledge of products offered by the Company
  • Ability to read and interpret complex policy contract language and correspondence including knowledge of Medicare forms and medical terminology
Benefits
  • Medical, dental, and vision plans to ensure your health and that of your family.
  • A 401k plan with employer matching to help you build a secure financial future.
  • Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.
  • Paid holidays.
  • Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.
  • Diversity and inclusion initiatives that embrace a wide range of perspectives and experiences.

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard skills
claims processingauditing claimslong-term care insurancemedical records reviewregulatory compliancefraud identificationdocumentation accuracypolicy interpretationMedicare knowledgeattention to detail
Soft skills
organizational skillscustomer serviceteamworkoral communicationwritten communicationinterpersonal skillsanalytical skillsproblem-solving skillssense of urgencypositive attitude