Claims Adjudicator Sr

Loma Linda University Health • Redlands, CA

1d • Onsite

About The Position

The Claims Adjudicator Sr is responsible mentoring and training Claims Adjudicators. The Lead will also analyze and process professional and hospital HMO Risk claims in accordance with the managed care contract provisions in an accurate and timely manner. Responds to questions from other adjudicators and processors. Verifies system assigned risk pool determination in accordance with the Division of Financial Responsibility matrix. Assists Director in creating, reviewing, and enhancing policies and procedures governing full risk claims processing on an annual basis or as needed. Assists other adjudicators and/or examiners as needed in order to assure that claims are completed within standards. Performs other duties as needed.

Requirements

• High School Diploma or GED required.
• Minimum five years managed care claims processing experience with professional and/or institutional claims required.
• Extensive experience in health insurance claims processing, HMO claims or managed care environment is required.
• In-depth knowledge of medical billing and coding.
• Knowledge of health insurance, HMO and managed care principles.
• Knowledge of Claims Payment System including Claim Hierarchy Categories, CPT, ICD-10, HCPCS, UB-04.
• Knowledge in UB and HCFA-1500 Insurance Claims.
• Ability to read and interpret Contracts and DOFR.
• Understanding of all CMS guidelines and regulations in relation to Claims Processing and Payments.
• Able to read; write legibly; speak in English with professional quality.
• Use computer, printer, and software programs necessary to the position (e.g., Word, Excel, Outlook, PowerPoint).
• Operate/troubleshoot basic office equipment required for the position.
• Able to relate and communicate positively, effectively, and professionally with others.
• Able to work calmly and respond courteously when under pressure.
• Able to collaborate and accept direction.
• Able to communicate effectively in English in person, in writing, and on the telephone.
• Able to think critically.
• Able to manage multiple assignments effectively.
• Able to organize and prioritize workload.
• Able to work well under pressure.
• Able to problem solve.
• Able to recall information with accuracy.
• Able to pay close attention to detail.
• Able to work independently with minimal supervision.
• Able to distinguish colors as necessary.
• Able to hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace.
• Able to see adequately to read computer screens, and written documents necessary to the position.
• Valid California Driver's License required at time of hire.

Nice To Haves

• Associate's Degree preferred.

Responsibilities

• Mentoring and training Claims Adjudicators.
• Analyzing and processing professional and hospital HMO Risk claims in accordance with managed care contract provisions accurately and timely.
• Responding to questions from other adjudicators and processors.
• Verifying system assigned risk pool determination in accordance with the Division of Financial Responsibility matrix.
• Assisting Director in creating, reviewing, and enhancing policies and procedures governing full risk claims processing.
• Assisting other adjudicators and/or examiners as needed to assure claims are completed within standards.
• Performing other duties as needed.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: High school or GED