Claims Examiner I

Clever Care Health Plan•Huntington Beach, CA

6d•$27 - $32•Hybrid

About The Position

Under close supervision, Claims Examiner I process non-complex paper or electronic claims, handling from inception to conclusion within established authority and guidelines. This position requires considerable interaction with clients, claimants on the phone, with management, other Claims Examiners, and other staff in the office; therefore, consistently being at work in the office or home office location as applicable, in a timely manner, is inherently required of this position.

Requirements

Associate degree. Bachelor’s degree in related field preferred
One (1) year related experience; or equivalent combination of education and experience.
Technical knowledge of statutory regulations and medical terminology.
Familiar with CMS claims payment, billing guidance.
Knowledge of CPT, HCPCS and ICD-10 diagnosis codes.
Strong analytical skills, including the ability to analyze and organize data.
Strong attention to detail.
Excellent organizational, oral presentation and written and verbal communication skills
Proficiency in MS Office products, including PowerPoint, Excel, and Word

Responsibilities

Be familiar and comply with all company policies and procedures.
Effectively manages a caseload of 50-150 claims a day
Initiates and conducts claim investigation in a timely manner.
Achieve claims processing standards for accurate and timely claims adjudication.
Maintain claims processing standards to meet performance appraisal goals.
Determines compensability of claims and administer benefits, based upon product benefits and CMS guidelines.
Manages medical treatment and medical billing, authorizing as appropriate, with requests for surgical treatment to be referred to supervisor prior to authorizing.
Communicates with provider regarding claims issues
Computes and processes payment.
Finalizes all claims and obtains authority as designated.
Maintains documentation in file to reflect the status of and work being performed on the file.
Communicates appropriate information promptly to the client to resolve claims efficiently.
Involves supervisory staff when appropriate.
Adheres to all Company policies and procedures.
Participates in audits and file reviews, as needed.
Performs other duties as assigned to include but not limited to assisting Document Processing Associate.
Other duties as assigned, mailroom tasks.