Claims Examiner
About The Position
We are seeking a detail-oriented professional to manage D-SNP pended claims and ensure compliance with regulatory guidelines. This role involves: Researching, correcting, and responding to all D-SNP pended claims in a timely manner. Reviewing audit reports and determining claim payment eligibility in accordance with policies and procedures. Maintaining accurate documentation for procedures, medical codes (CPT, HCFA), and correspondence. Reviewing, pricing, and releasing claims for assigned claim types (paper and electronic). Monitoring and reviewing manual reports that suspend for D-SNP claim review. Staying current on all D-SNP policies and contributing to departmental improvement projects. Maintaining a daily activity log and assisting with claims processing. Performing other duties and projects as assigned.
Requirements
- Claims processing
- Healthcare knowledge
Nice To Haves
- Experience with QNXT
- Strong knowledge of the D-SNP program
- Expertise in dual-eligible claims processing (Medi-Cal and Medicare D-SNP)
- Prior experience in a high-volume production environment
- Excellent oral and written communication skills
- Strong attention to detail
- Medical terminology and/or coding experience (highly desirable)
Responsibilities
- Researching, correcting, and responding to all D-SNP pended claims in a timely manner.
- Reviewing audit reports and determining claim payment eligibility in accordance with policies and procedures.
- Maintaining accurate documentation for procedures, medical codes (CPT, HCFA), and correspondence.
- Reviewing, pricing, and releasing claims for assigned claim types (paper and electronic).
- Monitoring and reviewing manual reports that suspend for D-SNP claim review.
- Staying current on all D-SNP policies and contributing to departmental improvement projects.
- Maintaining a daily activity log and assisting with claims processing.
- Performing other duties and projects as assigned.
Benefits
- Medical, dental & vision
- Critical Illness, Accident, and Hospital
- 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
- Life Insurance (Voluntary Life & AD&D for the employee and dependents)
- Short and long-term disability
- Health Spending Account (HSA)
- Transportation benefits
- Employee Assistance Program
- Time Off/Leave (PTO, Vacation or Sick Leave)
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What This Job Offers
Career Level
Entry Level
Education Level
No Education Listed
Number of Employees
5,001-10,000 employees
