Medical Claims Examiner III / Specialist

Responsibilities :

Parameters of the provider's contract obligations.

Audit claims processing quality, develops, maintains and runs standard reports

Assist the Claims Supervisor / Director in reviewing the quality auditing tracking / reporting (financial and procedural)

Coordinating with various departments to resolve disputes or issues

Maintain the Claims department workflow

Review and process hospital claims and complicated claims to assist claims examiners I, and II

Claims processing to ensure quality (in / out patient hospital claims, Medi-cal, Commercial, and Medi-care claims)

Review auto adjudication of claims

Review carve-outs in the Division of Financial Responsibility (DOFR)

Review and process reports and work with management and claims unit

Assist the Claims Manager in reviewing the quality auditing tracking / reporting

Assist with training / supporting the claims team

Recommend and assist in the development of process improvements

Coordinating with various departments to resolve disputes or issues

Able to process a claim and assist the team by answering questions and providing support

Prepare for check runs

Other duties may be assigned as needed to assist the AMM team

Basic policies and operations of health care insurance plans.

Federal, State and local rules and regulations as they relate to claims processing.

Modern office practices and procedures.

Business mathematical computation.

Computer application related to the work.

Required Skills and Abilities

High School Diploma or GED, some college preferred

3-5 years of claims examiner experience processing professional and facility claims

Strong analytical and problem solving skills are necessary

Know the industry guidelines for all LOBs

Proficient with medical terminology, CPT, Revenue codes, ICD-10,

Medicare and Medi-Cal claims adjudication experience required.

Knowledge of claims processing rules, managed care benefits and adjudication

Strong analytical skills and problem-solving skills are necessary.

Familiarity with Medicare guidelines and ICE compliance guidelines

Experience with the handling of claims in a managed care business (HMO)

Extensive knowledge of claims processing and claims data analysis

Experience with EZ-Cap and Encoder Pro preferred

Must be familiar with Microsoft Office (Word, Excel, Outlook)

Desired Skills and Experience

This position is open to Hybrid schedules in the greater Southern California area (Preferably near Los Angeles / Long Beach).

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status.

We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.

For unincorporated Los Angeles county , to the extent our customers require a background check for certain positions, the Company faces a significant risk to its business operations and business reputation unless a review of criminal history is conducted for those specific job positions.