Job Description:

UMMARY OF POSITION: 

 

Under the guidance and direction of the Team Leader (Claims Supervisor), the Process Executive (Claims Examiner) is responsible for the quality production, adjudication, and cycle time of claims.  This position will adhere to all corporate guidelines while processing claims in a timely and efficient manner and placing a strong emphasis on quality work.  

 

MAJOR DUTIES AND RESPONSIBILITIES:

 

MEET and maintain individual quality and productivity standards and claim cycle time. 

 

INTERPRET and apply appropriate processing policies, procedures and guidelines while interacting with on-line systems edits/pends.  

 

PROCESS, review and investigate facility or professional claims by applying appropriate contractual benefit provisions, riders, waivers, and provider contracts.

 

PROCESS claim pends to correct and/or finalize the claim on a timely and accurate basis.

 

UTILIZE knowledge of procedure codes (i.e. CPT), diagnosis codes (i.e. ICD-9), and POS/TOS codes to render accurate claims decisions.

 

ANALYZE patient and medical information to identify whether investigation for Coordination of Benefits, Subrogation, Worker’s Compensation or No Fault is necessary and to be encountered.

 

INFORM management of processing, systems, procedural issues and/or problems that may be encountered.

 

INITIATE system generated and/or form letters (e.g. requests for Medical Records or claims denials).       

 

PERFORM various related duties as assigned.

 

This description is not an exhaustive list.

 

 

 
Qualifications - External

QUALIFICATIONS:

 

Education/Experience:  The ideal candidate will possess a high school diploma (two years of college preferred) and preferably with 6 months - 2 years on claims adjudication experience or in a managed care experience, or comparable experience in medical billing/coding.  The qualified candidate must be able to successfully complete the Claims Training curriculum.

 

Skills/Knowledge/Competencies:  The ideal candidate will demonstrate proficiency in medical terminology, procedure and diagnosis coding in order to ensure comprehension of the overall claims process.  Familiarity with the universal facility or professional claim/billing forms is required.  The ability to perform in a high production environment and meet or exceed individual and departmental productivity and quality standards is required.  Strong written and oral communication skills and analytical ability with attention to detail are essential to success. The incumbent must have the ability to work independently to complete assigned tasks.

 

 

Cognizant will only consider applicants for this position whom are legally authorized to work in the United States without requiring company sponsorship now or at any time in the future.

 

Domain Skills

SNo	Primary Skill	Proficiency Level *	Rqrd./Dsrd.
1	Underwriting(Healthcare)	PL4	Required
2	Customer Service-Healthcare	PL4	Required

 

* Proficiency Legends

Proficiency Level	Generic Reference
PL1	The associate has basic awareness and comprehension of the skill and is in the process of acquiring this skill through various channels.
PL2	The associate possesses working knowledge of the skill, and can actively and independently apply this skill in engagements and projects.
PL3	The associate has comprehensive, in-depth and specialized knowledge of the skill. She / he has extensively demonstrated successful application of the skill in engagements or projects.
PL4	The associate can function as a subject matter expert for this skill. The associate is capable of analyzing, evaluating and synthesizing solutions using the skill.

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