Senior Examiner, Claims

JOB DESCRIPTION Job Summary Provides senior level 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. • Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication, and recommends solutions to resolve issues. • Identifies and recommends solutions for error issues as it relates to pre-payment of claims. • Monitors the medical treatment of claimants...