Claims Examiner I/II - Temporary

Kern Family Health Care•Bakersfield, CA

12d•Hybrid

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

Health maintenance organization (HMO) (Payer) claims payment-processing experience is required
High School Diploma from an accredited school or equivalent.
Up to (1-2) years of medical claim payment or medical billing processing experience
Experience investigating COB.
Ability to calculate usual and prevailing fees.
Must have claims examiner experience as a payor.
Computerized on-line data entry systems
organizational structure of medical claims processing
methods and procedures utilized in medical claims processing
medical terminology
CPT & ICD-9 coding
COB & subrogation investigation.
Adapt to a rapidly evolving work environment
work independently
communicate with a variety of personnel and providers.
Knowledge of: Computerized on-line data entry systems; organizational structure of medical claims processing; medical terminology; HCPCS, CPT & ICD-10 coding, UB04 and CMS1500 forms.

Nice To Haves

Health maintenance organization (HMO) claims payment-processing experience is highly desirable.

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 guidelines.
Perform other job-related duties as required.
Regular Predictable attendance.
Adheres to all company policies and procedures relative to employment and job responsibilities.