About the position
We are looking for a detail-oriented individual that can accurately review, research, and analyze professional claims to determine and calculate the type and level of benefits based on established criteria and provider contracts. The ideal candidate will have experience in adjudication of Commercial, Medicare Advantage, and Medi-Cal claims, along with familiarity with the Healthcare Service industry, Independent Physician Associates (IPAs), and/or experience in a Managed Care/Service Organization (MSO) or Health Plan background. This position is full-time and offers a work-life balance, with a commitment to providing quality service in the healthcare sector. As a Claims Examiner, you will be responsible for identifying authorizations and matching them to claims, troubleshooting and answering claims questions for both internal and external stakeholders, and adjudicating claims in the correct financial banks. You will also be tasked with identifying dual coverage and potential third-party liability claims, coordinating benefits for management approval, and updating the system insurance coverage profile. A strong understanding of health plan Division of Financial Responsibilities and contract verbiage is essential, as well as the ability to support the Claims Departments and other Examiners in troubleshooting claims issues. Documenting the resolution of claims to support claim payment and/or decisions is also a critical part of this role. The nature of the role may require adaptation to changing circumstances and additional responsibilities not explicitly mentioned here. The organization reserves the right to modify, interpret, or supplement the job duties as needed. We value our team's opinions and new ways of getting the job done and are looking for self-starters with fresh ideas, ready to help pave the way to a better tomorrow.
Responsibilities
- Identifying authorizations and matching authorization to claims.
- Troubleshooting and/or answering claims questions to internal/external stakeholders.
- Adjudicating claims in the correct financial banks.
- Identifying dual coverage and potential third-party liability claims.
- Coordination of Benefits to management for approval and updating system insurance coverage profile.
- Understanding and interpreting health plan Division of Financial Responsibilities and contract verbiage.
- Supporting the Claims Departments and other Examiners and troubleshoots Claims issues for internal/external stakeholders.
- Documenting resolution of claims to support claim payment and/or decisions.
Requirements
- High School Diploma and/or equivalent work experience in managed care/services, health plan, and/or IPA.
- Minimum of 1 year of related claims processing experience in managed care/services, health plan, and/or IPA (preferred).
- Knowledge of HCFA 1500 forms, CPT, and ICD codes (required).
- Strong understanding of division of financial responsibility for determination of financial risk.
- Practical knowledge and understanding of relevant business practices and applicable regulations/policies.
- Excellent written and verbal communication.
- Strong contract verbiage and knowledge of claims processing software.
- Able to sit for long periods of time.
- Professional behavior, good business judgement and strong team interaction skills.
- Valid Driver's License or able to reliably commute to the office.
- U.S. Work Authorization (required).
Benefits
- Medical
- Dental
- Vision
- Paid Time off
