Claims Examiner Iii

Wage Range: $31.00/hour - $33.50/hour

Job Summary

Under the direction of the Claims Manager, the Claims Examiner III reviews and adjudicates complex or specialty claims, submitted either via paper or electronically. The Claims Examiner III performs advanced administrative/operational/customer support duties that require independent initiative and judgment. This includes but is not limited to; Inpatient, COB high dollar, dialysis, oncology/chemo, home health agency, SNF, hospital exclusions and claim adjustments in an accurate and expedient manner. The position also includes auditing of professional claims for accuracy using, CCI edits, CMS LCDs, NCDs, and other Plan policies.

Functions & Job Responsibilities

• The Claims Examiner III determines whether to return, deny, or pay Institutional claims following organizational policies and procedures.
• Conducts end to end claims audits to ensure claims are processed accurately according to benefits assignment, applicable contracts, pricing, and configuration rules.
• Ensures Institutional claims also meet compliance guidelines.
• Performs claims testing on claims configuration and enhancements.
• Decisions are typically focused on methods, tactics, and processes for completing administrative tasks/projects.
• Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
• Adjudicates complex professional and institutional claims.
• Assist with training and mentoring of new team members.
• Assist with the testing of new claim processing procedures or projects.
• Responsible for meeting performance measurement standards for productivity and accuracy.
• Adjudication of claim adjustments.
• Review and correct claims involving data integrity issues.
• Interface with other Clever Care Departments, when necessary, regarding claims issues.
• Participate in Claims Department Team Meetings, and other activities as needed.
• Supports all department initiatives in improving overall efficiency.
• Identifies and recommends solutions for error issues as it relates to pre-payment of claims.
• Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication and recommending solutions to resolve these issues.
• Manages a caseload of various types of complex claims. Procures all medical records and statements that support the claim.
• Meets department quality and production standards.
• Meet State and Federal regulatory Compliance Regulations on turnaround times and claims payment for multiple lines of business
• Other duties as assigned.

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Qualifications

Education & Experience:

• Associate degree or equivalent combination of experience in health insurance or related fields, which would provide the necessary knowledge, skills and abilities to successfully perform the work
• Bachelor's degree preferred
• Two (2) years’ experience in examining and processing Institutional claims for Inpatient, Dialysis, SNF, Home Health using Medicare prices
• Two (2) years’ experience in examining and processing medical claims professional or institutional
• Experience Medicare/Medi-Cal experience preferred.
• Claim adjustments, provider appeals and/or disputes preferred.

Skills:

• Advanced knowledge and skills in medical terminology, HCPCS/CPT, and ICD-9/ICD-10
• Knowledge of Centers for Medicare and Medicaid services claims payment guidelines.
• Strong analytical skills, including the ability to analyze and organize data.
• Strong attention to detail.
• Excellent organizational, oral presentation and written and verbal communication skills.
• Proficiency in MS Office products, including PowerPoint, Excel and Word.
• Ability to provide effective leadership and direction within an organization.
• Meets and consistently maintains production standards for Claims Adjudication.

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required  
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

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