Job Purpose

The Claims Examiner I is responsible for the processing and/or adjusting and the releasing of hospital or medical claims according to 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

• Complies with all Company and Department Policies and Procedures.

• Processing claims for all lines of business.

• Requesting and reviewing medical records as needed for basic information to validate billing information.

• Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated.

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

• Identify claims payment errors through issues assigned by manager during day-to-day operation, report to department manager to correct/resolve them.

• Must meet quantitative production standard of 100 - 150 claims per week.

• Must maintain an error accuracy of under 5%.

• Meeting and exceeding performance measurements for Claim Examiners as required by department to meet regulatory compliance.

• Participate in claims workflow projects.

• Attend weekly or monthly departmental meetings and provide feedback when requested.

• When needed assist in claims audit activities.

• Support other departments as needed.

• All other duties as assigned.

Qualifications

• 2+ 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.

• Experience with EZ-Cap and Encoder preferred.

• Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe • Detail oriented and highly organized

• 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.

• Must work well under pressure and deadlines.

• Strong written and verbal communication skills

Salary Range

• $18.00 - $25.00 per hour

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