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Job Description

We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and/or health plan environment. This position will accurately review, research, and analyze professional claims for a managed service organization (MSO). They will need to be able to work independently and multitask appropriately to make benefit determinations and calculations of type and level of benefit based on established criteria and provider contracts. In-depth knowledge of Health Plans, IPA, and MSO functions, departments, and claims processing procedures are required. This position will need experience in understanding and interpreting fee schedules, eligibility, DOFRs, and contracts, and will assist in identifying and resolving root causes of claim issues.

Position Specs:

• Non-Exempt
• Full-Time
• Benefits-Eligible: PTO, PSL, Holidays, 401(k), Flexible Spending Account, Work/Life Balance, Unpaid Time Off.
• Schedule: Monday - Friday; can discuss scheduling, but typical office hours of 8:30 am - 5:30 pm (your choice of 30 minutes or 60 minutes lunch).
• Salary Range: $24-$37 per hour, depending on experience and knowledge.

Some Major Duties include:

· Identifies authorizations and matches authorization to claims and claim concerns.

· Adjudicate claims in the correct financial banks. Identified dual coverage and potential third-party liability claims. Refers claims with Coordination of Benefits to Management to approve and update system insurance coverage profile.

· Determines out-of-network and out-of-area services or providers and processes in accordance with company and governmental guidelines.

· Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.

· Processes all claims, eligible or ineligible, accurately conforming to quality and production standards and specifications in a timely manner.

· Supports other Examiners in adjudicating claims from payors.

· Adjudication of Commercial, Medicare Advantage, and Medi-Cal claims.

· Documents resolution of claims to support claim payment and/or decisions.

· Demonstrates professional behavior, good business judgement and strong team interaction skills.

· Troubleshoots and resolves inquiries pertaining to Claims Department from internal and external stakeholders.

· Read and interpret provider contracts to ensure payment/denial accuracy.

· Read an interpret Medicare Fee schedules.

· Identifies root causes of claims payment errors and reports any issues pertaining to claims to Management.

· Generates and develops reports which includes but not limited to root causes of provider disputes.

· Collaborates with other departments and/or providers in successful resolution of claims related issues.

· Assist in the creation of business rules and training in order for Claims Department to become more efficient and accurate.

· Attend meetings as needed pertaining to Claims and provide feedback when requested.

· Travelling may be required for check runs – active and valid driver license and car insurance is required.

· Other projects and duties as assigned.

EDUCATION

· High School diploma and equivalent work experience in the managed care industry is required.

EXPERIENCE

· 3+ years of related claims processing in a managed care organization such as managed service organization, IPA, and/or Health Plan experience.

· Claims processing for Medicare.

· Knowledge in Medicare rules and regulations.

· Knowledge of medical terminology.

· Medi-Cal Claims processing knowledge is a plus.

· Substantial practical knowledge and understanding of relevant business practices and applicable regulations/policies pertaining to Claims processing.

· Knowledge of HCFA 1500 forms, CPT and ICD codes.

· Experience in reading and interpreting DOFRs and Contracts.

· Experience and knowledge in Microsoft Office applications, such as Word and Excel.

SKILLS/KNOWLEDGE/ABILITIES

· Understand division of financial responsibility for determination of financial risk.

· Excellent and effective communication, interpersonal, and organization skills.

· Multitasking skills.

· Ability to be proactive and work independently.

· Excellent written & oral communication skills.

· Excellent computer and typing skills.

· Excellent customer service and conflict resolution abilities.

· Ability to maintain the highest standards of confidentiality and HIPAA.

· Ability to work with a high degree of integrity to perform objective and constructive audits.

· Ability to self-motivate to meet deadlines.

· Cultivate strong working relationships with other internal and external stakeholders.

· Ability to keep track of projects and deadlines, and follow up with any pending issues.

· Ability to accept responsibility and possess the desire to learn new tasks and/or make processes more efficient.

Compensation details: 24-37 Hourly Wage

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