Job Description
Job title:
Claims Examiner
Reports to:
Claims/Recovery Manager
Job purpose:
The Claims Examiner is responsible for the processing and/or adjusting and the releasing if hospital or medical claims according o established policies and procedures. Must identify procedural and system inefficiencies and work with the appropriate entities to resolve issues. Examiners also perform research, analysis, reporting and special projects as assigned. Examiners must be able to meet production requirements and quality standards.
Duties and responsibilities:
- Participate in claims workflow projects.
- Complies with all Company and Department Policies and Procedures.
- When needed assist in claims audit activities.
- Ability to resolve claims issues on identified processing errors and make recommendations for improvements to avoid error
- Identify any overpayment underpayment in a review and or history search. Follow department protocol for reporting and following up.
- Adjusts voids and reopens claims within guidelines to ensure proper adjudication.
- Resolve any grievances and complaints received through Customer Services, responds when needed to telephone and written inquiries and initiates steps to assist callers regarding issues relating to the content or interpretation of benefits, policies and procedures, provider contracts, and adjudication of claims.
- Support the Claims Department as business needs require.
- May have customer/client contact.
- May assist with training of staff. Works without significant guidance.
- Support other departments as needed.
- All other duties as assigned.
Qualifications
- 5+ years or more experience in processing HMO claims in a managed care environment.
- Familiar with all regulatory requirements including CMS, DMHC and DHS.
- Proficient with all Federal and state requirements in claim processing.
- Knowledge of medical terminology and coding.
- Proficient in rate application for outpatient PPS & Inpatient DRG facility, ASC, APC, Interim Rate Payment methods to applicable lines of business. (Medicare, Commercial, Medi-Cal).
- Recognize the difference between Shared Risk and Full Risk claims.
- Proficient in and knows how to use and apply Health Plan Benefit Matrices and Division of Financial Responsibility.
- Proficient understanding of AB1324.
- Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations.
- Excellent communication skills including reports, correspondence, and verbal communications.
- Demonstrated proficiency with Outlook, Word, Excel and Adobe.
- EzCap experience preferred.
- Strong ability to multi-task, project management, and work in a fast-paced environment.
- Strong ability in problem-solving.
- Ability to self-manage, strong time management skills.
- Ability to work in an extremely confidential environment.
Working conditions:
- This job may require flexible work hours due to the nature of the responsibilities.
Job Type: Full-time
Pay: $20.00 - $25.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Flexible schedule
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Schedule:
- Monday to Friday
Application Question(s):
- How many years of processing HMO claims in a managed care environment do you have?
Experience:
- EzCap: 1 year (Preferred)
Work Location: Remote