Claims Examiner

Alhambra, CA 91801

Employment Type: Direct Job Category: Claims Job Number: 46298

Are you an experienced medical claims rockstar? Are you organized, detail-oriented, and efficient? If you have experience with medical claims within a managed care setting. My client, A rapidly growing healthcare organization in San Gabriel Valley is looking to expand its Claims department.

SUMMARY

Process and adjudicates facility UB04 and professional CMS-1500 claim in accordance with all claims policies, contracts, keeping in compliance with industry regulations and guidelines

.ESSENTIAL DUTIES AND RESPONSIBILITIES, include the following:

Adjudication for Projects and Priority Claims, Health Plan Demand Letters, Correspondences, Hospital, Anesthesia, ER, Unaffiliated Specialists and Medicare claim to include the accurate

Apply all claims policies, contracts, practices and keep in compliance with industry regulations and guidelines

Comply with claims timeliness guidelines: commercial 45 working days; Medi-Cal 30 calendar days; Medicare non-contracted 30 calendar days and Medicare contracted 60 calendar days

. Proficient in and performs the application of Coordination of Benefits

. Proficient with all Federal and state requirements in claim processing

. Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations.

Proficient in rate application for outpatient PPS & Inpatient DRG facility, ASC, APC, Interim Rate and CMAC Rates of Payment methods to applicable lines of business. (Medicare, Commercial, Medi-Cal, Healthy Families and Healthy Kids)

Ability to resolve claims issues on identified processing errors and make recommendations for improvements to avoid error

Resolve any grievances and complaints received through Customer Services

Prompt and accurate response to claims related questions from Management.

Recognize the difference between Shared Risk and Full Risk claims.

EDUCATION and/or EXPERIENCE

High school diploma or general education degree (GED).

Two years of related experience and/or training in the HMO/Healthcare field.

MATHEMATICAL SKILLSAbility to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.

Our client, a large, rapidly growing healthcare organization is in need of a claims examiner to join their team!

  • This is a direct-hire, full-time salaried position with benefits, generous PTO and Holiday Pay
  • Schedule is Mon-Fri, 8a.m. - 5p.m. office-based setting, with opportunity for growth and career development
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