Medical claims examiner job description

This post includes 3 parts: duties list, job qualification and job description writing tips for Medical claims examiner in details. A complete job description concludes Medical claims examiner key duties/responsibilities, Medical claims examiner job qualifications (knowledge, education, skills, abilities, experience…KSA model) and other ones such as daily tasks, key activities, key/core competencies, job functions/purpose…

I. List of Medical claims examiner duties:

1. Determines covered medical insurance losses by studying provisions of policy or certificate.
2. Establishes proof of loss by studying medical documentation; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims.
3. Documents medical claims actions by completing forms, reports, logs, and records.
4. Resolves medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter.
5. Ensures legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
6. Maintains quality customer services by following customer service practices; responding to customer inquiries.
7. Provides legal support by assembling documentation for settlement action.
8. Protects operations by keeping claims information confidential.
9. Prepares reports by collecting, analyzing, and summarizing information.
10. Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations.
11. Accomplishes organization goals by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.

II. List of Medical claims examiner qualifications

1. Three (3) plus years experience processing multispecialty and hospital provider claims
2. Knowledge of DMHC and CMS rules and regulations
3. Comprehensive knowledge, use and application of CPT, ICD9 codes
4. Comprehensive knowledge, use and application of universal claims forms, UBO4, CMS1500
5. Strong written, verbal and interpersonal communication skills
6. Must be detailed oriented, selfdirected/motivated
7. Excellent Documentation skills
8. Knowledge of FDA Health Regulations
9. Excellent math skills

III. Tips to write job description

1. Too-long job description:

Looking at a too-long job description can frighten the candidates off and drive the away. A job description, no matter how important the job is, should not be included in more than 3 pages. If one focuses on too many things at a time, he shall definitely lose focus on the main items and get overwhelmed by the remaining; So, keep it concisely.

2. Too-short job description:

While too-long can be a problem, too-short is more a problem. It will ruin the meaning of the job description. A too-short one means it lacks necessary details and therefore, the candidate will not be able to understand while reading it.

3. Listing unnecessary functions or job duties:

Just classifying these into the “others” category will save you a lot of effort and space. On the other hand, the job description will become more dilute and easy to be neglected.

4. Key functions

Not listing key functions as required for the job can be a fatal mistake to a job description.

5. Grammar and spelling

Poor grammar and having spelling errors can ruin the job description, too. Never think that as you are the employer, you may have the right to make grammar or spelling errors while requires other not to. A job description with such errors is easily to be mistaken as a fake or ghost ads; as a result, the candidate will turn away from it.

6. Not specific enough:

Be specific and concise; if you don’t address the specific, then what the job description is for. It is for the candidate to understand just exactly what he needs to do or needs to have. Lacking details can confuse the candidates very well.

7. Not having the job description reviewed by others:

This is also a common mistake. One may be subject to bias, but more than one, especially with the help of those external advisor, the job description can be more perfect.

8. Using buzzwords or abbreviations:

In fact, it is not necessary at all to use such in a job description.

9. Using slang or legal words:

Just use common wording to communicate with others and don’t do anything extraordinarily.

10. Not updating the job description:

The same job may require different duties and responsibilities in different times, so, you cannot use the same job description for 2 different times.

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