Senior Claims Examiner

WelbeHealth

About The Position

At WelbeHealth, we are transforming the reality of senior care by providing an all-inclusive healthcare option to the most vulnerable senior population, while serving as a care provider and care plan to those individuals we serve. Our Health Plan Services team helps ensure excellent care delivery for our participants, and the Senior Claims Examiner plays a pivotal role in ensuring timely and efficient processing of claims for our contracted specialty provider partners.

Requirements

Minimum of three (3) years’ health plan claims processing experience, and two (2) years’ health plan claims dispute experience analyzing and resolving provider claims problems
Experience in a Managed Care Plan (MCP) or PACE organization (PO) claims processing environment highly preferred
In depth experience with Medicare and Medicaid claims processing
Strong computer and appropriate software knowledge (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word, Teams) and job specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position
Ability to balance competing priorities, exercise discretion, and consider all relevant factors in navigating gray areas and resolving ambiguities
Proficient in the principles and practices of managed health care, health care systems and medical terminology (e.g., revenue Codes, Current procedural Terminology (CPT), Healthcare Common Procedure Coding system (HCPCS) and Internal Classification of Disease (ICD-10)
Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee schedule and Diagnosis Related Groups (DRG) and benefit interpretation and administration

Responsibilities

Examine claim records and forms to investigate and resolve first level disputes, including completion of acknowledgement and determination letters
Review and process second level claims, such as adjustments and corrected claims
Work closely with leadership on identified trends related to improper processing and claim-related concerns or discrepancies that result in a dispute
Assist the team in carrying out departmental responsibilities and collaborate with others to support short- and long-term goals and priorities
Establish and maintain effective working relationships with team and collaboration with interdepartmental staff and leadership