Claims Examiner – Health Plan

Location: Orange, CA
Date Posted: 02-01-2018
Claims Examiner – Managed Care
Orange, CA
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 5-6 months, or longer! ***

Your Job Summary:
The primary role of the Claims Examiner is to provide support for data information needs in the medical management departments.  The Claims Examiner is responsible for performing financial and operational analysis, and preparing reports for a variety of areas including claims, premiums, calculating medical loss ratio (MLR), and other quality data. They will complete reporting and analysis related to claims and operations, identifying trends and opportunities for cost-effective quality improvement strategies. Their focus is to analyze and resolve pending and denied encounters based on federal and state guidelines. 

Your Reward:   


Your Background:  
Requires an education level of at least a high school diploma or GED.
Prefer, but does not require, a Certified Health Data Analyst (CHDA) or similar.
At least 1-2 years experience processing on-line claims in a managed care environment.
Around 4-5 years in member services or health data analysis experience, preferably in managed care environment.
Knowledge of health care delivery system, Medicaid/Medicare, related state programs, and dual eligibility programs required.
Strong working knowledge of concepts, practices, and procedures related to managed care / practice management.
Established experience with database management system. 
Basic familiarity with Medical terminology is required.
Computer skills to include Microsoft Word, Excel and basic data entry, including the ability to learn new and complex computer system applications.
Your Duties:
The Claims Examiner collaborates with internal departments to facilitate encounter resolution process to meet department and individual encounter resolution targets and deadlines.  The Claims Examiner develops and maintains a data analysis and reporting process that supports the distribution of reports to internal staff or delegated groups.  They are accountable for optimal usage of the existing data systems, including data mining, data summarizing, data validation and data integrity.  Interprets needs and specifications in creating analytical reports, in order to provide internal staff, delegated groups, and affiliated providers with actionable reports.  Responsible for providing some oversight and coordination for designated claims or quality initiatives, which includes analyzing, monitoring, and reporting their effectiveness. Review, analyze, and report financial and claims data. Create and maintain monthly electronic dashboards with performance metrics for departments and leadership to review and measure performance effectiveness.  Analyze current operational procedures, identify issues, and recommend process workflows or solutions, including automating processes and improving encounter resolution methodology.
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