Claims Examiner III

Astrana Health, Inc.•Monterey Park, CA

6d•$28 - $32•Hybrid

About The Position

Job Title: Claims Examiner III Department: Ops - Claims Ops What You'll Do Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-10 codes, under the correct provider and member benefits Review and process facility (UB-04) and professional claims (CMS-1500) Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups’ and company policies and procedures Process Medicare member claims based on DMHC and DHS regulatory legislature Respond to and resolve provider and health plan claims inquiries and give resolution in a timely manner Review services for appropriateness of charges and apply authorization guidelines during claims processing Monitor and track age, pended, and open reports to maintain timeliness in claims processing based on individual work allocation reports Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines Participate in special projects, complete tasks assigned by management and attend meetings/conference calls as necessary Loading and entering claims Other duties as assigned

Requirements

Must have at least 3 years of applicable healthcare claims adjudication experience within the managed care industry for a level I or II and at least 4 years for Senior level claims
Must be familiar with ICD-10, HCPCS, CPT coding, APC, ASC and DRG pricing, CMS, DMHC regulations, facility and professional claim billing practices
Must possess proficient filing, general clerical, verbal and written communication and presentations skills
Must be able to problem-solve, follow guidelines, multi-task, and work comfortably within a team-oriented environment
Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and Ez-cap Claims adjudication software, preferred
Ability to type with accuracy and speed of at least 35 wpm
Associate's degree (A. A.) or equivalent from two-year college or technical school; some college courses, or six months to one year related experience and/or training; or equivalent combination of education and experience

Nice To Haves

Candidates with multi-product line claims adjustment experience, preferred
Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and Ez-cap Claims adjudication software, preferred

Responsibilities

Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-10 codes, under the correct provider and member benefits
Review and process facility (UB-04) and professional claims (CMS-1500)
Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups’ and company policies and procedures
Process Medicare member claims based on DMHC and DHS regulatory legislature
Respond to and resolve provider and health plan claims inquiries and give resolution in a timely manner
Review services for appropriateness of charges and apply authorization guidelines during claims processing
Monitor and track age, pended, and open reports to maintain timeliness in claims processing based on individual work allocation reports
Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines
Participate in special projects, complete tasks assigned by management and attend meetings/conference calls as necessary
Loading and entering claims
Other duties as assigned