Claims Examiner

Department: Ops - Claims SoCal

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Compensation: $20.00 - $24.00 / hour

Description

We are currently seeking a highly motivated Claims Examiner. This role will report to the Manager - Claims and enable us to continue to scale in the healthcare industry.

Our Values:

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team
  
  

What You'll Do

• Performs through review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services
• Processes non-institutional claim types for all line of business (Medicare, Medical, Commercial, etc)
• The Specialist should clearly understand the products and healthcare benefits services offered to customers, including cost share, limits and regulatory rules and guidelines
• Configure provider contracts, Fee schedule updates and other documents
• Develop configuration testing & validate accuracy of data loaded
• Communicated required system updates to Provider Contracting & Claims operations
• Coordinate research & resolution of debarred & sanctioned providers
• Corrects system generated errors manually prior to final claims adjudication
• Communicated required system updates to Provider Contracting & Claims operations
• Process claims based upon the provider's contract/agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and NMM policies and procedures
• Analyzes and validates Medi-cal pricing researches, Adjusts and adjudicates claims reviews services for accurate charges and utilizes current billing code sets, (i.e International Classification Diseases (ICD 10) Codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference
• Validates eligibility and other possible health insurance coverage on the claims (i.e Medicare primary, California Children services (CCS),,)
• Alerts manager or supervisor of more complex issues that arise
• Processes claim exception reports as assigned
• Recognize claim correspondences from multiple IPAs
• Recognize the health plan financial risk (Division of Financial Responsibility)
• Recognize the difference between Shared Risk and Full Risk claims
• Maintain required levels of production and quality standards as established by management
• Attendance at employer worksite is an essential job requirement
• Work assigned claim project to completion
• Contribute to team effort by accomplishing related results as needed
  
  

Qualifications

• Strong understanding of claims lines of business (Medicare, Medical, Commercial, etc)
• Knowledge of MS Word, Excel and basic medical terminology
• High School graduate or equivalent
• Excellent knowledge of CPT, HCPCS, ICD-10 CM, ICD-10 PCS, etc
• Typing speed 70+ WPM and knowledge of 10 key desired
• Ability to multi-task and meet deadlines
• Strong organization skills; ability to multitask and properly manage time
• Position may require unscheduled overtime, week-end work
• Ability to understand work with proprietary software applications
• Organizational ability and ability to exercise good judgment
• Work independently as part of a team
• At least 2 year plus of claims processing experience in the health insurance industry or medical health care delivery system
  
  

You're great for this role if:

• Have EZ-CAP knowledge
  
  

Environmental Job Requirements And Working Conditions

• Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754.
• The total compensation target pay range for this role is: $20.00 - $24.00 per hour. This salary range represents our national target range for this role.
  
  

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at [email protected] to request an accommodation.

Additional Information:

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.