Claims Examiner II/III

2 weeks ago


La Puente, California, United States Innovative Management Systems Incorporated Full time
:

We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and/or health plan environment. This position will accurately review, research, and analyze professional claims for a managed service organization (MSO). They will need to be able to work independently and multitask appropriately to make benefit determinations and calculations of type and level of benefit based on established criteria and provider contracts. In-depth knowledge of Health Plans, IPA, and MSO functions, departments, and claims processing procedures are required. This position will need experience in understanding and interpreting fee schedules, eligibility, DOFRs, and contracts, and will assist in identifying and resolving root causes of claim issues.

Position Specs:

  • Non-Exempt
  • Full-Time
  • Benefits-Eligible: PTO, PSL, Holidays, 401(k), Flexible Spending Account, Work/Life Balance, Unpaid Time Off.
  • Schedule: Monday - Friday; can discuss scheduling, but typical office hours of 8:30 am - 5:30 pm (your choice of 30 minutes or 60 minutes lunch).
  • Salary Range: $24-$37 per hour, depending on experience and knowledge.

Some Major Duties include:

Identifies authorizations and matches authorization to claims and claim concerns.

Adjudicate claims in the correct financial banks. Identified dual coverage and potential third-party liability claims. Refers claims with Coordination of Benefits to Management to approve and update system insurance coverage profile.

Determines out-of-network and out-of-area services or providers and processes in accordance with company and governmental guidelines.

Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.

Processes all claims, eligible or ineligible, accurately conforming to quality and production standards and specifications in a timely manner.

Supports other Examiners in adjudicating claims from payors.

Adjudication of Commercial, Medicare Advantage, and Medi-Cal claims.

Documents resolution of claims to support claim payment and/or decisions.

Demonstrates professional behavior, good business judgement and strong team interaction skills.

Troubleshoots and resolves inquiries pertaining to Claims Department from internal and external stakeholders.

Read and interpret provider contracts to ensure payment/denial accuracy.

Read an interpret Medicare Fee schedules.

Identifies root causes of claims payment errors and reports any issues pertaining to claims to Management.

Generates and develops reports which includes but not limited to root causes of provider disputes.

Collaborates with other departments and/or providers in successful resolution of claims related issues.

Assist in the creation of business rules and training in order for Claims Department to become more efficient and accurate.

Attend meetings as needed pertaining to Claims and provide feedback when requested.

Travelling may be required for check runs - active and valid driver license and car insurance is required.

Other projects and duties as assigned.

Requirements:

EDUCATION

High School diploma and equivalent work experience in the managed care industry is required.

EXPERIENCE

3+ years of related claims processing in a managed care organization such as managed service organization, IPA, and/or Health Plan experience.

Claims processing for Medicare.

Knowledge in Medicare rules and regulations.

Knowledge of medical terminology.

Medi-Cal Claims processing knowledge is a plus.

Substantial practical knowledge and understanding of relevant business practices and applicable regulations/policies pertaining to Claims processing.

Knowledge of HCFA 1500 forms, CPT and ICD codes.

Experience in reading and interpreting DOFRs and Contracts.

Experience and knowledge in Microsoft Office applications, such as Word and Excel.

SKILLS/KNOWLEDGE/ABILITIES

Understand division of financial responsibility for determination of financial risk.

Excellent and effective communication, interpersonal, and organization skills.

Multitasking skills.

Ability to be proactive and work independently.

Excellent written & oral communication skills.

Excellent computer and typing skills.

Excellent customer service and conflict resolution abilities.

Ability to maintain the highest standards of confidentiality and HIPAA.

Ability to work with a high degree of integrity to perform objective and constructive audits.

Ability to self-motivate to meet deadlines.

Cultivate strong working relationships with other internal and external stakeholders.

Ability to keep track of projects and deadlines, and follow up with any pending issues.

Ability to accept responsibility and possess the desire to learn new tasks and/or make processes more efficient.



Compensation details: 24-37 Hourly Wage

PIf3aefdb72bf6-9770


  • Credit Officer II

    2 weeks ago


    La Jolla, California, United States City National Bank Full time

    Overview: CREDIT OFFICER II - PBB WHAT IS THE OPPORTUNITY? Participates in the loan management process by providing credit and loan underwriting expertise to a team of Personal & Business Banking Relationship Managers. Is client facing and manages all aspects of credit relationships for clients. Provides credit product expertise in an advisory capacity and...

  • Material Handler

    2 weeks ago


    La Mirada, California, United States Revolution Full time

    **Description** **Details of Position** This is a **Full-Time** position **Location:** La Mirada, CA **Job Schedule:** Sunday - Thursday, 6:30 AM - 2:00 PM **Starting Pay:** $15.00 per hour + **$500 Sign-On Bonus**** Position is immediately available **Position Summary** The Materials Handler is responsible for counting and staging raw materials for use on...

  • Licensed Therapist

    4 weeks ago


    La Mirada, California, United States Pinnacle Treatment Centers Full time

    Overview: We offer competitive salary, full benefits package, Paid Time Off, and opportunities for professional growth.Aegis / Pinnacle Treatment Centers is a nationally recognized leader in addiction treatment services that has been featured in publications such as: LA Times, NBC Today, US News, Health Digest, Medscape, and Huffington Post.Through our...

  • Licensed Therapist

    1 month ago


    La Mirada, California, United States Pinnacle Treatment Centers Full time

    Overview: We offer competitive salary, full benefits package, Paid Time Off, and opportunities for professional growth.Aegis / Pinnacle Treatment Centers is a nationally recognized leader in addiction treatment services that has been featured in publications such as: LA Times, NBC Today, US News, Health Digest, Medscape, and Huffington Post.Through our...


  • La Mirada, California, United States DAVITA Full time

    14337 Imperial HWY, La Mirada, California, , United States of AmericaJoining DaVita as Patient Care Technician (PCT) is an exciting opportunity to jump start your career in the health care industry. With paid, extensive training, you will gain the skills needed to care for our patients and build a network of other health care professionals across the...


  • La Mirada, California, United States DAVITA Full time

    14337 Imperial HWY, La Mirada, California, , United States of AmericaJoining DaVita as Patient Care Technician (PCT) is an exciting opportunity to jump start your career in the health care industry. With paid, extensive training, you will gain the skills needed to care for our patients and build a network of other health care professionals across the...


  • La Mirada, California, United States City of Norwalk Full time

    The City of Norwalk is currently seeking an experienced Public Services Superintendent to fill a vacancy in the Public Services Department. This position involves planning and managing the day-to-day activities of staff and operations of the various sections within the Public Services Department, under administrative direction. The Public Services...

  • Claims Examiner II/III

    2 months ago


    La Puente, United States Innovative Management Systems, Inc. Full time

    Job Type Full-time Description We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and/or health plan environment. This position will...


  • La Puente, United States Innovative Management Systems, Inc. Full time

    Job Type Full-time Description We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and/or health plan environment. This position will...

  • Claims Examiner

    2 weeks ago


    La Puente, United States Innovative Management Systems, Inc. Full time

    Job Type Full-time Description The Position. We are looking for a detail-oriented individual that can accurately review, research, and analyze professional claims to determine and calculate the type and level of benefits based on established criteria and provider contracts. Experience in adjudication of Commercial, Medicare Advantage, and Medi-Cal claims...

  • Claims Auditor

    2 months ago


    La Puente, United States Innovative Management Systems, Inc. Full time

    Job Type Full-time Description THE POSITION. This position is responsible for reviewing and processing claims, including facility claims, to ensure accuracy prior to payment release. This position is the lead responder to Health Plans and IMS Clients for all products and lines of business. Responsible for management and monitoring of claims compliance with...

  • Claims Auditor

    2 weeks ago


    La Puente, United States Innovative Management Systems, Inc. Full time

    Job Type Full-time Description THE POSITION. This position is responsible for reviewing and processing claims, including facility claims, to ensure accuracy prior to payment release. This position is the lead responder to Health Plans and IMS Clients for all products and lines of business. Responsible for management and monitoring of claims compliance with...


  • La Mesa, United States City of La Mesa, CA Full time

    **Position Summary**: **Future Scheduled Salary Increases**: **3.5% increase effective July 1, 2024** **_ ~ Additional salary step scheduled to be added to the Salary Range for this position effective July 1, 2024 ~_** *** - Possession of an appropriate, valid Class B driver's license - Experience performing a variety of semi-skilled and skilled tasks...


  • La Conner, United States WaveDivision Holdings LLC Full time

    DescriptionBroadband Network Technician I, II or III LaConner, WA Astound Broadband, the sixth-largest telecommunications provider in the United States, is a leading supplier of cutting-edge technology and communications services-and applicants like you make it all possible. To develop your career, we provide one-on-one training and coaching, a supportive...


  • La Conner, United States WaveDivision Holdings LLC Full time

    DescriptionBroadband Network Technician I, II or III LaConner, WA Astound Broadband, the sixth-largest telecommunications provider in the United States, is a leading supplier of cutting-edge technology and communications services-and applicants like you make it all possible. To develop your career, we provide one-on-one training and coaching, a supportive...


  • La Conner, United States WaveDivision Holdings LLC Full time

    DescriptionBroadband Network Technician I, II or III LaConner, WA Astound Broadband, the sixth-largest telecommunications provider in the United States, is a leading supplier of cutting-edge technology and communications services-and applicants like you make it all possible. To develop your career, we provide one-on-one training and coaching, a supportive...


  • La Grange, United States PARKS AND WILDLIFE DEPARTMENT Full time

    GENERAL DESCRIPTION Under the direction of the DISTRICT 9, this position is responsible for performing the professional planning and implementation of natural resource management, monitoring, and research duties associated with wildlife and habitat resources in Fayette counties within the Post Oak Savannah and Blackland Prairies ecological region of the...


  • La Grange, United States PARKS AND WILDLIFE DEPARTMENT Full time

    **TPWD - Natural Resources Specialist I - II - III (District Biologist)** **(**00041993**)** **Organization**: PARKS AND WILDLIFE DEPARTMENT **Primary Location**: Texas-La Grange **Work Locations**: WL-District 9 111 E. Travis, Suite 200 La Grange 78945 **Job**: Management **Employee Status**: Regular **Schedule**: Full-time **Standard Hours Per...

  • Instructional Aide Ii

    4 weeks ago


    La Puente, United States Hacienda La Puente Unified School District Full time

    **APPLICATIONS MAY BE FILED ONLINE AT**: Contact: Maria Murillo 15959 E. Gale Avenue City of Industry, CA 91745 626 933-3923 **ONE-DAY RECRUITMENT EVENT** **Tuesday, June 11, 2024 or Wednesday, June 12, 2024** **(Applications Due: May 28, 2024)** **How To Apply**: 2. Applicants who meet the minimum requirements will be invited to the event. You will be...

  • Instructional Aide Ii

    8 hours ago


    La Puente, United States Hacienda La Puente Unified School District Full time

    **APPLICATIONS MAY BE FILED ONLINE AT**: Contact: Maria Murillo 15959 E. Gale Avenue City of Industry, CA 91745 626 933-3923 **ONE-DAY RECRUITMENT EVENT** **Tuesday, June 11, 2024 or Wednesday, June 12, 2024** **(Applications Due: May 28, 2024)** **How To Apply**: 2. Applicants who meet the minimum requirements will be invited to the event. You will be...

  • X-ray Level Ii

    3 weeks ago


    La Porte, United States Howmet Aerospace Full time

    We’re a company of innovators and makers. Howmet Aerospace is transforming the aerospace and transportation industries. Join our team and help us engineer the next generation of sustainable travel. Our state-of-the-art investment casting facility in La Porte, Indiana is nestled halfway between South Bend and Chicago, along the shores of Lake Michigan -...


  • La Porte, United States Revak Keene Turbomachinery Full time

    Job Reports To : General Manager Purpose of Job : As Quality Inspector Level III, you are responsible for ensuring the products we produce are of consistently high quality and adhere to relevant specifications. As QC Inspector Level III, you are an invaluable member of our manufacturing team, ensuring the highest quality of production from receiving...


  • La Porte, United States Revak Keene Turbomachinery Full time

    Job Reports To : General Manager Purpose of Job : As Quality Inspector Level III, you are responsible for ensuring the products we produce are of consistently high quality and adhere to relevant specifications. As QC Inspector Level III, you are an invaluable member of our manufacturing team, ensuring the highest quality of production from receiving...

  • Financial Analyst

    4 weeks ago


    La Puente, United States Bassett Unified School District Full time

    **BASIC FUNCTION & DISTINGUISHING CHARACTERISTICS**: **THIS POSITION IS DUAL CERTIFICATION AND IS OPEN TO BOTH INTERNAL AND EXTERNAL CANDIDATES** **Vacancies: 1** **Hours: 8 Hours/Day (**Monday - Friday** 8:00 AM - 4:30 PM)** **Months: 12** - (Classification Specification pending California School Employees Association approval)_ **_BASIC...


  • La Puente, United States CEDARS-SINAI Full time

    Job Description Make a difference every single day! When the work you do every single day has a crucial impact on the lives of others, every effort, every detail, and every second matters. This shared culture of happiness, passion and dedication pulses through Cedars-Sinai, and it’s just one of the many reasons we’ve achieved our sixth-consecutive...


  • La Palma, United States City of La Palma, CA Full time

    **Description**: **This is an open recruitment to fill current and future full-time vacancies.** **The incumbent will enjoy working a 4/10 work schedule (Monday through Thursday) not including overtime or on-call shifts.** **This position will receive a 5% cost of living adjustment effective July 1, 2024.** The incumbent will enjoy a family environment...


  • La Porte, United States Acuren Inspection, Inc. Full time

    Position Summary: Acuren is currently recruiting for an NDT Level II Technician. **Responsibilities**: - Set up and calibrate nondestructive testing equipment - Conduct tests to ensure quality or detect discontinuities (defects) using NDT methods of inspection - Establish techniques for proper examination of objects under inspection, ensuring strict...