Medicare Claims Examiner
About The Position
The Medicare Claims Examiner (D-SNP) reviews and processes Medicare and Medi-Cal claims in a fully remote role. The position researches and resolves pended and denied claims, determines payment eligibility, adjudicates claims, and ensures work complies with applicable Medicare, Medi-Cal, CMS, and health plan guidelines. It also involves maintaining coding documentation, communicating claim issues and resolutions to internal departments, identifying trends, and supporting process improvements. Candidates must reside in California and have hands-on QNXT experience. This is a contract opportunity based out of Irvine, California, with potential for extension based on performance and business needs. Equipment is provided by CenCal Health.
Requirements
- At least 3 years of Claims Examiner or healthcare claims processing experience.
- Medicare and/or Medi-Cal claims processing experience.
- D-SNP experience.
- Health plan experience.
- Strong understanding of claims adjudication and payment determination.
- Experience working in a high-volume production environment.
- Knowledge of CPT, HCPCS, ICD, and HCFA coding.
- Medical terminology knowledge.
- Strong analytical, organizational, and communication skills.
- Ability to work independently in a remote environment.
- Proficiency with Microsoft Office and claims processing systems.
- QNXT experience is required.
- Medicare Advantage and/or D-SNP experience is required.
- Must currently reside in California.
- Must be comfortable working in a production-driven environment.
Responsibilities
- Review, research, price, and process paper and electronic claims.
- Research and resolve pended and denied D-SNP claims.
- Determine claim payment eligibility and accurately adjudicate claims.
- Review manual review and audit reports.
- Maintain documentation related to CPT, HCPCS, ICD, and HCFA coding.
- Ensure compliance with Medicare, Medi-Cal, CMS, and health plan guidelines.
- Communicate with internal departments regarding claim issues and resolutions.
- Identify trends and support process improvement efforts.
- Meet productivity, quality, and turnaround-time expectations.
Benefits
- Medical insurance, if eligible.
- Dental insurance, if eligible.
- Vision insurance, if eligible.
- Critical illness, accident, and hospital coverage, if eligible.
- 401(k) retirement plan with pre-tax and Roth post-tax contributions available, if eligible.
- Voluntary life and AD&D insurance for employees and dependents, if eligible.
- Short- and long-term disability coverage, if eligible.
- Health Spending Account (HSA), if eligible.
- Transportation benefits, if eligible.
- Employee Assistance Program, if eligible.
- Time off/leave, including PTO, vacation, or sick leave, if eligible.
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What This Job Offers
Career Level
Mid Level
Education Level
No Education Listed
