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Claims Examiner

Orange, CA · Healthcare
Claims Examiner – Health Plan 
Orange, CA
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 5-6 months, or longer! ***

Claims Examiner Job Summary: 
  • Analyzes and processes claims, and is responsible for following regulatory and internal guidelines in conjunction with policies and procedures as they apply to claims adjudication. 
  • Responsible to adjudicate more complex claims, requiring additional research or problem solving.
  • Responsible for accurate and timely adjudication of claims according to guidelines.
  • Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue, ICD-9 and ICD-10 codes, under the correct provider and member benefits, i.e. co-payments, deductibles, etc.
  • Claims processing based upon contractual agreements, involving the use of established payment methodologies, Division of Financial Responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures.
  • Alerts manager or supervisor of issues that impact production and quality, i.e. incorrect database configurations, non-compliant claims, etc.
  • Responds to incoming calls from providers of service in a timely and courteous manner.
  • Resolves issues as presented or as referred by the examiners.
  • Process claims based on compliance regulation and timeframes.
  • Process both professional (CMS-1500) and facility (UB-04) claim types.
  • Maintain quality and productivity standards as set by management.
  • Resolve provider or physician group (network) claims inquiries and apply resolution in a timely fashion.
  • Responds to questions from examiners. Explains processing guidelines and internal processes when needed.
  • Review services for appropriateness of charges and apply authorization guidelines during claims processing.
  • Prepare written requests to providers; follow up and handle completion of claim for returned correspondence.

Claims Examiner 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.
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