Claims Examiner I
Kern Family Health Care•Bakersfield, CA
•$21 - $26•Onsite
About The Position
Under management direction, responsible for reviewing and processing all types of medical and facility claims from contracting and non-contracting providers and from subscribers and enrollees for payment in an accurate and timely manner. Responsible for applying correct contract benefits, policies and procedures. This position is responsible for claims auditing and payment functions for a Knox-Keene licensed health maintenance organization (HMO).
Requirements
- High School Diploma from an accredited school or equivalent.
- Minimum of one (1) year medical Claims Examiner processing experience.
- Individual must have good organizational skills and the ability to make good decisions.
Responsibilities
- Resolve system suspended claims for: PCPs Labs Radiology Less complicated specialists Physical Therapy
- Deny inappropriate claims following policy guidelines.
- Prepare claims that must be routed to other departments for further review.
- Review difficult claims with guidance from Claims Supervisor.
- Responsible for identifying billing errors and possible fraudulent claims submissions.
- Obtain eligibility verification and other health insurance coverage by Internet or POS.
- Responsible for correct manual calculation of benefits when applicable.
- Responsible for identifying possible CCS eligible claims for further investigation.
- Report overpayment refund requests on SharePoint log
- Maintain productivity and quality in accordance with established guideline.
- Perform other job-related duties as required.
- Regular Predictable attendance.
- Adheres to all company policies and procedures relative to employment and job responsibilities.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Upload and Match Resume
What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
