Claims Examiner III

Responsible for consistently and accurately adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy.

Process claims according to all CMS and DMHC guidelines.

Review, research and process complex claims.

Handle recalculation of claims due to incorrect claim payments or where additional information has been received.

Investigate and complete open or pended claims.

Meet production and quality standards.With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island.

Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services.

Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare.

For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care.

We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives.

Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans / CMS.

Minimum Education : High school diploma or equivalent required. Minimum Experience : Three to five (3-5) years prior medical claims processing experience required.

Knowledge of general claims processing principles, CMS claims coding, and UB-04 claims coding, based on at least three to five (3-5) years experience in claims processing preferably in a managed care environment (IPA,MSO) Req.

Certification / Licensure : None.

Enter claims information from CMS 1500 (professional) and UB-04 (facility) claims into the IDX claims system.

Process all level of claims including Professional, COB, surgery, skilled nursing, lab, Home Health, ER, hospital (in and outpatient), DME, Pharmacy and radiology claims by applying Prospect's policy and procedures and all claim payment criteria.

Analyze complex claim issues and handle all adjustments for corrected claims or when additional information previously requested is received.

• Identify and pend claims that require referrals to all support areas (eligibility, Medical management etc) for evaluation or correction of data, tracking these claims to ensure that they are returned and resolved within regulatory guidelines.
• Achieve stringent quality goals of 98% administrative accuracy and 99% financial accuracy to contribute to achieving client performance expectations.
• Achieve stringent productivity goals of 80 / 10 claims per day / hr.

Initiate recovery of overpaid claims.

Also any other duties as requested.

Enter claims information from CMS 1500 (professional) and UB-04 (facility) claims into the IDX claims system.

Process all level of claims including Professional, COB, surgery, skilled nursing, lab, Home Health, ER, hospital (in and outpatient), DME, Pharmacy and radiology claims by applying Prospect's policy and procedures and all claim payment criteria.

Analyze complex claim issues and handle all adjustments for corrected claims or when additional information previously requested is received.

• Identify and pend claims that require referrals to all support areas (eligibility, Medical management etc) for evaluation or correction of data, tracking these claims to ensure that they are returned and resolved within regulatory guidelines.
• Achieve stringent quality goals of 98% administrative accuracy and 99% financial accuracy to contribute to achieving client performance expectations.
• Achieve stringent productivity goals of 80 / 10 claims per day / hr.

Initiate recovery of overpaid claims.

Also any other duties as requested.