Claims Examiner II- Bakersfield

Universal Healthcare MSO•Bakersfield, CA

2d•Onsite

About The Position

This position is non-exempt and will be paid on an hourly basis. The Claims Examiner II's primary responsibility will be to adjudicate medical claims within the claims transaction system. This involves verifying that information is accurately captured and complete in the database. The role will process both professional (CMS 1500) and institutional (CMS 1450/UB04) claims. During the verification process, the system will prompt audits on specific fields to ensure accuracy and completeness for each claim in the batch.

Requirements

High School diploma or equivalent.
Strong knowledge of professional and institutional claim processing procedures, including COB (Coordination of Benefits)/TPL (Third Party Liability)/WC.
Familiarity with CPT, HCPCS, ICD-10, ASA, Revenue Codes, etc.
Performs high volume data entry.
Strong background with system automation of claims processes and workflows.
Familiar with office equipment (including a photocopy machine, scanner, facsimile machine, etc.).
Proficiency in MS Excel, Word, and Outlook.
Ability to type 40-50 Words per minute (WPM) or 6,000 8,000 Keystrokes per Hour (KSPH).
One or more years working in a healthcare or other related business environment.
Possession of a valid driver's license.
Proof of state-required auto liability insurance.

Nice To Haves

Experience in medical billing services and/or managed care environment preferred.

Responsibilities

Follow written criteria, policies, and procedures to thoroughly review and process claims.
Evaluate claims for appropriateness of payment, considering factors such as eligibility, benefits, authorizations, coding, compliance, contracted payment terms or relevant fee schedule, and health plan contracts.
Stay informed about annual changes in contracts and apply the correct terms to claims, ensuring adherence to contracted payment terms and health plan agreements.
Ensure accurate and proper denial processing in the system for claims deemed inappropriate for payment, facilitating correct letter generation.
Consistently meet internal, external, and governmental timeliness standards in processing claims to ensure prompt and efficient service delivery.
Exercise the freedom to make decisions regarding payment or denial of medical services, handling sensitive and confidential information with utmost discretion.
Refer claims and accompanying documentation to the Utilization Management (UM) department if they do not align with department policy guidelines.
Interact with various stakeholders, including Eligibility, Member Services, UM, providers, Health Plans, and applicable staff, as needed for claim resolution.
Maintain compliance with established production and quality standards, ensuring accuracy and efficiency in claim processing.
Work independently on assigned tasks and activities based on established policies and procedures, demonstrating autonomy and accountability.
Other related duties as assigned.