Claims Examiner, Sr.

Job Summary

The Claims Examiner will be responsible for analyzing and validating claims elements and claims processing. The incumbent will adhere to the regulatory and internal guidelines in conjunction with the client's Health’s policies and procedures related to claims adjudication.

Position Responsibilities

• Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.
• Conducts research and problem solves the more complex claims.
• Processes professional and institutional claim types.
• Performs thorough review of pending claims for billing errors and questionable billing practices that might include duplicate billing and unbundling of services.
• Corrects system-generated errors manually prior to final claims adjudication.
• Processes claims
• Analyzes and validates Medi-Cal pricing; researches, adjusts and adjudicates claims; reviews services for accurate charges, utilizing billing code sets and/or authorization guidelines as a reference.
• Processes claim exception reports as assigned.
• Completes other projects and duties as assigned.

Possesses the Ability To:

• Meet and maintain established quality and production standards.
• Handle multiple tasks and meet deadlines.
• Work independently and as part of a team.
• Establish and maintain effective working relationships
• Communicate clearly and concisely
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.

Experience & Education:

• High School diploma or equivalent required.
• 3 years of experience processing online claims in a managed care environment required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications:

Knowledge of:

• Revenue codes and billing code sets, e.g., Current Procedural Terminology (CPT), Healthcare Common Procedural Coding System (HCPCS), International Classification Diseases (ICD-10) Codes and medical terminology.
• Industry pricing methodologies, such as Resource Based Relative Value Scale, Medi-Cal Fee Schedule, etc.
• Benefit interpretation and administration.
• Medicare/Medi-Cal guidelines and regulations.

Thanks for checking our Claims Examiner role out! ---------------------------------------------------------------------------------------------- For 32 years, the Midtown Group has been connecting talented professionals with incredible employment opportunities.

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