Home office claims examiner vs medical claims examiner

Differences between home office claims examiner and medical claims examiner duties and responsibilities

Home office claims examiner example responsibilities.

• Investigate, manage, negotiate and resolve claims arising out of accidents involving automobile and homeowner policies.
• Review and approve new applications in accordance to CIP guidelines.
• Provide technical support and direction as to case management, experts, litigation management and final authority on reportable claims.
• Participate in business process redesign in claims and litigation.
• Provide oversight for quarterly system testing ensuring system integrity are not compromise by directing consistent testing practices across multiple groups.
• Negotiate settlements and file arbitration or hire counsel when warrant.

Medical claims examiner example responsibilities.

• Manage cases by aggressively directing the litigation process.
• Process medical facility claims payment according to account-specific contract (HMO, PPO, EPO, etc . )
• Process PPO, HMO, comprehensive plans, including medicare supplements, hospital, chiropractic and physical therapy claims.
• Identify which claims are eligible for PPO reprising.
• Resolve medical claims by approving and/or denying base on CMS guidelines for Medicaid/Medicare claim processing.
• Verify that all ICD-9, CPT, modifiers and revenue codes are used correctly, prior to payment approval.
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