Claims Processor

DELTA HEALTH SYSTEMS MCC•Fresno, CA

1d•$21 - $31•Onsite

About The Position

Delta Health Systems, a third-party administrator for self-insured programs, is seeking an innovative, self-motivated, and dedicated Claims Processor. The position evaluates claims and determines payment or denial according to plan provisions, medical policy, and guidelines. It processes claim payments, maintains claim notes and benefit quote documentation, reviews patient and family notes, and uses external network pricing platforms while following network administrative agreements. The Claims Processor also establishes and maintains coordination of benefits (COB) files, applies COB payments, researches appropriate CPT procedure and ICD-10 diagnosis codes, and responds to written correspondence from participants, providers, local unions, and employers. The role works with Benefit Review and other departments, meets production, quality, and accuracy standards, attends required training and meetings, and assists other areas as workload requires.

Requirements

High school diploma or equivalent.
Eighteen months of experience as a Claims Processor or in a similar function.
Broad knowledge of medical terminology.
Excellent written and oral communication skills.
Good judgment and the ability to interpret department guidelines and contractual benefits.
Ability to operate under stress conditions with maturity and composure.
Excellent organization and assignment management skills.
Ability to navigate external network pricing platforms.
A medical terminology course may substitute for six months of equivalent experience.
Must not be in probationary status and must meet the stated qualifications to be eligible to apply.

Responsibilities

Evaluate claims and determine payment or denial according to plan provisions, medical policy, and guidelines.
Process claim payments thoroughly.
Attend training and refresher courses.
Maintain clear claim notes and benefit quote documentation, and thoroughly review patient and family notes.
Maintain access to multiple network pricing and authorization systems to avoid inactivity or processing disruptions.
Establish and maintain coordination of benefits (COB) files and apply COB payments toward final claim payment.
Research and determine appropriate CPT procedure and ICD-10 diagnosis codes.
Research and respond to written correspondence from participants, providers, and local unions or employers.
Transfer claims to Benefit Review for processing instructions or to other departments according to guidelines.
Meet at least the required production, quality, and accuracy standards.
Follow department policies and procedures.
Attend mandatory department meetings as scheduled.
Assist other department areas as required by workload and inventory needs.
Prioritize workload and adhere to network administrative agreements.
Maintain professionalism and communicate clearly with internal and external customers.
Perform other duties as assigned.