Claims Examiner I/II - Temporary

KHS•Bakersfield, CA

10d•$22 - $23•Hybrid

About The Position

This is a full-time temporary position where the Claims Examiner is 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. The role involves applying correct contract benefits, policies, and procedures, and performing claims auditing and payment functions for a Knox-Keene licensed health maintenance organization (HMO). The position may be filled at either the I or II level based on experience and qualifications.

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.
Knowledge of computerized on-line data entry systems.
Knowledge of the organizational structure of medical claims processing.
Knowledge of methods and procedures utilized in medical claims processing.
Knowledge of medical terminology.
Knowledge of CPT & ICD-9 coding.
Knowledge of COB & subrogation investigation.
Ability to adapt to a rapidly evolving work environment.
Ability to work independently.
Ability to communicate with a variety of personnel and providers.
Knowledge of 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, and 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.
Identify billing errors and possible fraudulent claims submissions.
Obtain eligibility verification and other health insurance coverage by Internet or POS.
Calculate benefits correctly when applicable.
Identify 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.
Maintain regular and predictable attendance.
Adhere to all company policies and procedures relative to employment and job responsibilities.