Claims Examiner

At P3 Health Partners, our promise is to guide our communities to better health, unburden clinicians, align incentives, and engage patients.

We are a physician-led organization relentless in our mission to overcome all obstacles by positively disrupting the business of health care, transforming it from sickness care into wellness guidance.

We are looking for a Claims Examiner. If you are passionate about your work; eager to have fun; and motivated to be part of a fast-growing organization in Henderson, NV or remote, then you should consider joining our team.

Claims Examiner 

Overall Purpose:

 This position is responsible for analyzing, validating, and adjudicating medical insurance claims by verifying member eligibility, benefits, authorizations and approving payment or denial according to contractual agreements, policies, health plan, state, and federal laws, in a timely and accurate manner. The position requires a basic understanding of claims adjudication and payment policies. Ability to work in a training and learning capacity until fully competent to independently process claims for inpatient, outpatient and professional services for contracted and non-contracted providers. The position focuses on the health plan side of claims processing. It does not involve medical claims submission, revenue cycle from a provider prospective, worker's compensation, or auto insurance claims.

Education and Experience: 

• High school diploma or GED
• Requires a minimum of 4+ years of experience in claims adjudication, in a managed care environment, specializing but not limited to professional claims adjudication and payment
• 2 years of Medicare Advantage (HMO) claims adjudication experience preferred
• Ez-Cap experience preferred

Knowledge, Skills and Abilities: 

• Must have a strong understanding of any local, state and federal rules regarding the adjudication of medical benefits.
• Personal computer with main frame emulation, claims management software, word processing and management software, 10-key adding machine, Imaging retrieval software, fax machine, copy machine, basic office aids.
• Strong knowledge of CPT, ICD-10 and CMS Guidelines for processing professional claims.
• Working knowledge of HMO operations, claims delegation compliance and contract interpretation.
• Ability to adhere to all departmental policies and processing guidelines
• Ability to deal with complex claim issues
• Ability to handle multiple projects and able to prioritize workload
• Demonstrated ability to work with and preserve confidential information
• Strong interpersonal, organizational, and critical thinking skills
• Ability to work without close supervision in a self-directed manner and also as a team member

• Ability to effectively communicate with internal and external associates
• Excellent communication and written skills
• A self-starter, passionate with a positive attitude

Essential Functions: 

• Adjudicates medical claims according to provider contracts, processing guidelines and in compliance with all state, federal and health plan laws & regulations, and CMS Guidelines maintaining a statistical and financial accuracy of 99%.
• Verifies patient eligibility, benefits and authorizations
• Prioritizes assigned claims according to regulatory timelines
• Requests additional information for incomplete or unclean claims; follows up as necessary
• Notifies Management immediately when claims cannot be processed within the processing timelines
• Documents medical claims actions by maintaining reports, logs, and records
• Maintains productivity and quality standards as defined by the Management
• Maintains quality customer services by following customer service practices; responding to customer inquiries
• Complies with company’s attendance and punctuality standards
• Promotes teamwork and cooperation with other staff members and management
• Ability to repeatedly produce high quality results
• Responsible for quality and continuous improvement within the job scope.
• Ability to function in a fast-paced environment while maintaining focus and control of workload
• Contributes to and supports the corporation’s quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation’s quality improvement efforts
• Other duties as assigned