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Form of workJob Description
This position is located in Cypress, CA
Southern California United Food & Commercial Workers Unions & Food Employers Joint Benefit Funds Administration, LLC (The Funds) were created more than 40 years ago as a result of collective bargaining between the Southern California Retail Food Employers and the Southern California UFCW Union Locals. The Funds serve in excess of 100,000 participants! There are two Funds, the Pension Fund and the Benefit Fund--through which member retirement and health and welfare benefits are provided.
The Funds Office is currently searching for a supportive Senior Medical Claims Adjuster, to join our growing team. In this role, you will be responsible for timely and accurate processing of exception and/or complex Medical Claims for the Plan's participants. This position is subject to Collective Bargaining.
General Responsibilities:
1. Ability to process various types of Medical claims with emphasis on complex claims, adjustments, Medicare Secondary Payer and Medicaid/Medi-Cal inquiries.
2. Provide support and expertise in reviewing and resolving appeals, customer service inquiries, provider claim inquiries and provider disputes.
3. Manage provider alerts for potential fraud, waste and abuse (FWA).
4. Proactively seeks assistance from the appropriate sources to accurately process claims and resolve claims related issues.
5. Interact effectively with other members of the department, the Fund and the Local offices in person or via email, telephone or other written or verbal.
6. Advise lesser experienced adjusters in the resolution/handling of more complex claims issues and assist with training as needed.
7. Interface and effectively manage participants, providers, vendors and other external clients when required in person or via email, telephone or other written.
8. Maintain current department knowledge of plan documents, summaries of plan provisions and other plan materials.
9. Meet or exceed established department production and quality standards on a weekly, monthly, quarterly and annual basis.
10. Proactively identify opportunities for improvement.
11. Actively participate in system testing when needed.
12. Handle all duties and assignments in a timely manner.
13. Perform other job related duties/special projects as assigned.
14. Abide by organizational and HIPAA guidelines, privacy practices, and confidentiality.
15.Comply with the policies of the Trust Fund, as set forth in the Employee Handbook.
16. Adhere to the company’s attendance policy.
Qualifications:
· High School diploma or GED required.
· 3-4 years of experience as a Medical Claims Examiner.
· Knowledge of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS), Medical Terminology.
· Knowledge with International Classification of Diseases (ICD) ICD-9/ICD-10 codes and guidelines.
· PPO claims processing experience, including prior experience in WGS processing system preferred.
· Exceptional Customer service skills\ with the ability to build rapport with Plan participants, team members and other employees of the Fund.
· Able to utilize MS Office (Excel, Word and Outlook) proficiency required.
The Funds is an equal employment opportunity employer and no candidate for employment will be rejected on the basis of race, color, religion, national origin, age, marital status, or sex. Candidates with physical impairments or limitations will be considered to the extent it can be reasonably demonstrated that the duties and responsibilities can be effectively performed without endangering the individual, colleagues or surroundings.
The Funds offers exceptional benefit packages that includes a 401(K) plan, pension plan, vacation, holiday, education reimbursement and much more!
