IMMEDIATE OPENING: MANAGED CARE EXPERIENCE ONLY

POSITION SUMMARY:

The Claims Examiner position is responsible for the claims processing, adjudication and claim research, where applicable. Must meet qualitative and quantitative standards established for this position. Assist Claims Management with audits and special projects as needed.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Performs thorough review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services.
• Adjudicate claims (paper and EDI) and resolve claim edits, using claims desk level and operational reference materials.
• Utilize our eHealthcare claims processing module in an effective and efficient manner to process claims
• Make appropriate decisions regarding the clearing of claim edits and payment of claims.
• Processes claims based upon contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and HealthSmart MSO’s policies and procedures.
• Meet production and quality standards when processing claims and performing tasks.
• Complete the manual pricing of claims according to provider contracts and other claims pricing references.
• Analyzes and validates Medi-Cal pricing; researches, adjusts, and adjudicates claims; reviews services for accurate charges and utilizes current billing code sets, i.e., International Classification Diseases (ICD10) codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference.
• Complete more complex claims processing tasks including claim adjustments, coordinating benefits with secondary carrier, claim reversals, etc.
• Handle smaller scale projects in claims from input to output.
• Work with Claims Management to resolve difficult or complex transactions and to identify system and/or training-related opportunities that will assist in operating results improvement.
• Respond to first and second level provider inquiries, claim status calls and faxes from provider.

Possesses the Ability To:

• Meet and maintain established quality and production standards.
• Work independently and as part of a team while providing excellent customer service skills.
• Develop and maintain effective working relationships with all levels of staff and providers.
• Handle multiple tasks and meet deadlines.
• Communicate clearly and concisely, both verbally and in writing.
• Utilize and access computer and appropriate software (e.g. Microsoft Office; Word, Excel, PowerPoint) and job-specific systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Qualifications:

• High school diploma or equivalent.
• A minimum of three years of Medicare and/or Medi-Cal, Commercial and Medicare Advantage/CalDual claims processing experience
• Knowledge of medical terminology, ICD-10, CPT, HCPCS and DRG coding, required.
• A minimum of three years of experience in a managed care organization, preferred.
• Excellent knowledge of claims systems.
• Ability to demonstrate organizational, interpersonal, and communication skills.
• Ability to maintain designated production and quality standards.
• Knowledge of different providers’ payment methodologies (i.e., capitation, fee for service based on RVRBS, Medi-Cal, Medicare and other negotiated flat rates, RVRBS pricing, Per Diem, DRG pricing, etc.), preferred.
• Ability to deal with complex claim issues.
• Knowledge of Medicare and Medi-Cal claims processing guidelines, Title 28 Claims Settlement Practices and other regulatory requirements.
• Proficient with Microsoft Office programs including PowerPoint, Outlook, Word, Excel and common computer equipment and office hardware.
• Ability to complete tasks in a timely manner.
• Ability to communicate effectively both verbally and in writing.
• Ability to work in a demanding environment and handle multiple projects at one time.
• Strong organizational skills and detail-oriented approach to work

Please submit resume and salary requirements

Job Type: Full-time

Benefits:

• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift

Education:

• High school or equivalent (Required)

Experience:

• Medicare/Medi-Cal, Commercial, Medicare Advantage claims: 3 years (Required)
• ICD coding, CPT, HCPCS & DRG coding: 3 years (Required)

Language:

• English (Required)

Work Location: Remote

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