Claims Examiner

3 weeks ago

Whittier, United States E-Solutions Full time

POSITION SUMMARY:

The claims examiner reports directly to the claims manager. They are primarily responsible for the processing functions (operation, adjudication, and payment) of UB-92 and HCFA-1500 claims that are received from PHP affiliated medical groups and hospitals for HMO patients.


EDUCATION/EXPERIENCE/TRAINING:

• Minimum of 2 years claims ADJUDICATION related experience in ambulatory, acute care hospital, HMO, or IPA environment

• Knowledge of payment methodologies for: Professional (MD), Hospital, Skilled Nursing Facilities, and Ancillary Services

* Knowledge and understanding of timeliness and payment accuracy guidelines for commercial, senior and Medi-Cal claims

* Knowledge of compliance issues as they relate to claims processing

• Experience in interpreting provider contract reimbursement terms desirable

• Ability to identify non-contracted providers for Letter of Agreement consideration

• Data entry experience

• Training on basic office automation and managed care computer systems

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