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Claims Examiner 


PeakTPA provides services that optimize your organization's financial management and fulfill regulatory requirements for health plan functions. Our expertise in health plan management, particularly in PACE, means you can focus on delivering high-quality care to your participants.

Job may be on-site or remotely based as long as candidates meet internet and other specific requirements.

Summary: Under the direction of the Claims Manager and assigned Supervisor, the Claims Examiner is responsible for processing claims and meeting defined quality and productivity standards.

Essential Functions:

Claims Processing and Payment

  • Evaluates claims for completeness and validity to determine payment/denial according to provider contracts, authorizations, and Medicare processing guidelines
  • Processes various Medicare and Medicaid claim types, including Professional, Facility and Dental claims
  • Accurately analyzes and interprets provider contracts
  • Researches claims and makes appropriate adjustments
  • Responds to clients inquiries related to claims processing

Additional Functions:

  • Communicates clearly and concisely, with sensitivity to the needs of others

  • Maintains courteous, helpful and professional behavior on the job; displays a willingness and ability to be responsive in a warm and caring manner to all customer groups; consistently cooperates and supports organization in problem solving issues; ensures customer satisfaction by understanding and applying the Customer Service Policy, Procedure and Standards; will support the success of the entire team; establishes and maintains effective working relationships with co-workers

  • Follows all Policies and Procedures and HIPAA regulations

  • Maintains a safe working environment

  • Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees

  • Establishes and maintains effective working relationships with co-workers
  • Participates in any required training sessions/seminars
  • Participates in special projects as requested

Supervisory Responsibility: None

Travel: Minimal travel, less than 10% is expected for this position. For remote positions, travel is required for initial training and for necessary, subsequent training. Travel may also be required for company events.

Position Requirements

Knowledge, Skills and Abilities:

  • Education/Experience – Educational requirements include a high school diploma or equivalent. Minimum of two years of claims processing experience required; PACE plan knowledge preferred.
  • Requires working knowledge of ICD-10, CPT, Revenue, and HCPCS coding, along with understanding of APC and DRG reimbursement.
  • Requires knowledge of current computer technology, including the use of computers; knowledge and proficiency with associated software, including Excel and Word
  • Skilled in establishing and maintaining effective working relationships with co-workers and clients
  • Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency
  • Detail-oriented with ability to focus for extended periods
  • Ability to work independently, seeking supervision as needed
  • Ability to communicate professionally, clearly and effectively, verbally and in writing
  • Ability to have superior attendance to effectively fulfill all functions of the position
  • Ability to independently follow through on assigned tasks, without prompting
  • Ability to prioritize effectively
  • Ability to multitask

Physical Demands & Requirements:

  • Communicates by way of the telephone with participants, customers, vendors and staff
  • Operates a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
  • Remains stationary for extended periods of time
  • Occasionally exerts up to 20 pounds of force to lift, carry, push, pull or move objects
  • Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
  • Frequent, repetitive use of hands/fingers entering information on a keyboard
  • Occasional reaching to retrieve shelved items

Work Environment:

  • This job operates in a home-office environment, or a professional office environment with a conversational noise level.
  • No substantial exposure to adverse environmental conditions is expected
  • Moderate pressure to meet scheduled appointments and deadlines
  • Potential for occasional verbal aggression by clients and vendors
Full-Time/Part-Time Full-Time  
Shift Days  
Position Claims Examiner  
Post Internal Days 0  
Number of Openings 1  
Location Peak Health Plan Management- St Louis, MO  
About the Organization  
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.  
Cell None Specified 

HoursPerWk None Specified 

supervisorUID None Specified 

This position is currently not accepting applications.

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