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Job Details

Claims Examiner II

Job Ref: 59023
Category: Claims
Department: CLAIMS
Location: 160 Water St. #3, New York, NY 10038
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $51,648.00
Salary Range: $51,648.00 - $51,648.00

About NYC Health + Hospitals

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview

The Claims Examiner II will service our customers by processing health care claim and by maintaining quality/production standards and guidelines as outlined by (CCI) the Correct Coding Initiative Edits. The position will analyze and adjudicate complex, difficult, and non-routine claim from multiple lined of business.
The ideal candidate will have experience processing healthcare claims in a high-volume claims department. Must be computer literate and have ability to enter data into computer system with speed and accuracy. Must be able to demonstrate time management and strong organizational skills.

Job Description

  • Process all claims identified as exceeding claim age parameters established within the unit (28+ days)
  • Process complex, difficult and non-routine claims for multiple lines of business
  • Audit work of assigned claims examiners to ensure quality
  • Provide audit statistics to Lead Auditor
  • Identify policies of common errors requiring retaining sessions
  • Assist with retraining sessions as directed
  • Participate in quality projects as required by management
  • Supervise the unit in the absence of the Supervisor

Minimum Qualifications

  • Master’s Degree from an accredited college or university in Management, Business Administration or an approved related field may be equated to a maximum of one year of the required experience
  • Bachelor’s Degree in a relevant field; and,
  • Minimum 3 years of claims experience in managed care or a hospital organization
  • One year in a supervisory capacity
  • Proficient data entry skills
  • Thorough knowledge of adjustment processing, medical terminology, CPT, IDC-p and RevenueCodes
  • Knowledge of software applications such as MS Word, Excel, or Access
  • Must be able to perform all the duties and responsibilities of subordinate claims examiners within the department.
  • Must be able to communicate adequately both verbal & written
  • Must have excellent interpersonal skills

Professional Competencies

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication