Claims Examiner

The Position.

We are looking for a detail-oriented individual that can accurately review, research, and analyze professional claims to determine and calculate the type and level of benefits based on established criteria and provider contracts. Experience in adjudication of Commercial, Medicare Advantage, and Medi-Cal claims will make you a great candidate, along with experience or familiarity with Healthcare Service industry, Independent Physician Associates (IPAs), and/or have experience in a Managed Care/Service Organization (MSO) or Health Plan background.

The Specs.

• Full-Time.
• Benefits Eligible: Medical, Dental, Vision, Paid Time off, and more.
• Non-exempt.
• Monday - Friday.
• Work-Life Balance.

The Duties.

• Identifying authorizations and matching authorization to claims.
• Troubleshooting and/or answering claims questions to internal/external stakeholders.
• Adjudicating claims in the correct financial banks.
• Identifying dual coverage and potential third-party liability claims.
• Coordination of Benefits to management for approval and updating system insurance coverage profile.
• Understanding and interpreting health plan Division of Financial Responsibilities and contract verbiage.
• Supporting the Claims Departments and other Examiners and troubleshoots Claims issues for internal/external stakeholders.
• Documenting resolution of claims to support claim payment and/or decisions.

*Please note that the duties and responsibilities outlined above are summarized and may not encompass all tasks associated with the position. The nature of the role may require adaptation to changing circumstances and additional responsibilities not explicitly mentioned here. The organization reserves the right to modify, interpret, or supplement the job duties as needed.

THE COMPANY.

Innovative Management Systems is a management services company focused on finding innovative ways to ensure regulatory compliance, customer services, provider experience, and measurable outcomes in the healthcare industry. Through our ever-evolving data analytics platform, we strive to improve overall medical spending, HEDIS, and STAR measures through a collaborative effort of education, reporting and workflow management. Come be part of the team that helps to improve quality of care, reduce administrative burden, and achieve greatness through creative thinking and educated calculated risks. Be the change in healthcare everyone talks about, but few people achieve. We value our team's opinions and new ways of getting the job done and are looking for self-starters with fresh ideas, ready to help pave the way to a better tomorrow.

We are an Equal Opportunity Employer and seek diversity in our workforce. We are also an E-Verify Employer, you can learn more about E-Verify program and your rights and responsibilities here: Learn More About E-Verify.

What You Need.

• High School Diploma and/or equivalent work experience in managed care/services, health plan, and/or IPA.
• Minimum of 1 year of related claims processing experience in managed care/services, health plan, and/or IPA (preferred).
• Knowledge of HCFA 1500 forms, CPT, and ICD codes (required).
• Strong understanding of division of financial responsibility for determination of financial risk.
• Practical knowledge and understanding of relevant business practices and applicable regulations/policies.
• Excellent written and verbal communication.
• Strong contract verbiage and knowledge of claims processing software.
• Able to sit for long periods of time.
• Professional behavior, good business judgement and strong team interaction skills.
• Valid Driver's License or able to reliably commute to the office.
• U.S. Work Authorization (required.)

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