Senior Claims Examiner - Full Time

UHS•Riverside, CA

14d

About The Position

Responsible for preparing, researching, analyzing, pre-coding and the adjudication of all types of claims (Contracted providers, Non-contracted, 1500 or UB claims forms, Senior and Commercial plans) received at RMC from outside providers for processing. Managed Care claims are processed in accordance with the outside Provider Contract, State, Federal, CMS, DMHC and Health Plan guidelines and regulations. Must maintain a processing standard of 10 claims per hour with a 90% level of accuracy, both clerical and financial.

Requirements

High school diploma or general education degree (GED); or three or more year’s related experience and/or training; or equivalent combination of education and or experience.
Knowledge and understanding of claims processing.

Responsibilities

Sort claims for adjudication according to type. If the claim is from a contracted provider, research the provider’s contract and verify the rate information.
Non-contracted provider claims, with or without prior authorization, are to be submitted to the Contracts Coordinator for a Letter of Agreement, on a Green “LOA Request Form”, prior to processing.
Pre-code claims, with the provider identification number, rates to be paid, EOB code, authorization and co-pay (if applicable) prior to entering the claims in the Managed Care system.
Re-verify that the patient account, family member number, date of birth, and HMO insurance information is correct, prior to entering the claim.
Claims are entered in to the computer system and to be adjudicated according to all State, Federal regulations, CPT, DX, Correct Coding, health plan, provider contracts and departmental policies and guidelines, either for pend, payment or denial.
If the service the provider is billing was not prior authorized, and the claim is NOT an Emergency Department visit, and the claim was not billed with pertinent medical information in order to make a payment determination, request the additional information, from providers outlining the specific information required. Status the claim using EOB code “P3” and follow up as required.
If a claim was billed with invalid CPT or Diagnosis codes, deny claims as “incomplete/unclean”, and note the specific reason in the claim notes.
When a Case Manager in the Utilization Management department reviewed a claim retrospectively, and a determination was made to deny the claim to the member; process the denied claim in the system, using EOB code 3.UM. Review claim to ensure appropriate denial letters have been attached prior to closing the batch.
Enter all member denials in to the computer system immediately upon receipt to ensure closure no later than the following week check run.
Ensure that all claims that have been identified as ERISA, and a determination has been made to deny to the member, adjudicate and close the claim within 30 calendar days from receipt.
Once the claims have been adjudicated in the system, match complete claims with the batch edit and review the processed claims for accuracy, prior to closure.
Once the edit has been reviewed ensure all matching documentation is attached, and forward to the Claims Auditors for review.
Notify management when claims cannot be processed within regulatory guidelines for timely claim processing.
Maintain productivity and accuracy standards of 10 claims per hour with a 90% level of financial and clerical accuracy.