Claims Examiner

The Claims Examiner’s duties and responsibilities are to adjudicate both hospital and professional claims in an efficient, cost-effective and timely manner. Responsible for determining financial responsibility between group, health plans and contracted hospitals for accurate processing of claims.

Essential Responsibilities:

The following are essential job duties and responsibilities and are not intended to represent an all-inclusive listing of related essential functions of the position:

• Interprets contract coverage for medical HMO claims.
• Review and interpret provider contracts to properly adjudicate claims.
• Review and interpret Division of Financial Responsibility (DOFR) for claims processing.
• Perform delegated duties in a timely and efficient manner.
• Verify eligibility and benefits as necessary to properly apply co-pays.
• Strong working knowledge of Medicare and Medi-Cal,
• Understands eligibility, enrollment and authorization process.
• Knowledge of prompt payment guidelines for clean and unclean claims.
• Process claims efficiently and maintains acceptable quality of at least 95% on reviewed claims.
• Prepares claims for medical review and signature review per processing guidelines.
• Identify correct received date on claims, with knowledge of all time frames for meeting compliance for all lines of business.
• Maintains good working knowledge of system/internet and on line tools used to process claims
• Good knowledge of CPT/HCPCS/ICD-10, and Revenue Codes, including modifiers.
• Researches authorizations and properly selects appropriate authorization for services billed.

Qualifications:

• 1 year claims processing experience, preferably in an IPA or Medical Group.
• Knowledge of managed care claims processing and compliance.
• Proficient in CPT, HCPCS, ASA and ICD-9 coding.
• 10-Key by touch.
• EZ-CAP experience preferred

Job Type: Full-time

Pay: $17.00 - $21.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work Location: In person