Claims Examiner
2 months ago
GENERAL SUMMARY
The Claims Examiner position is primarily responsible for the accurate and timely adjudication of paper and/or electronically formatted claims received in the CMS 1500 and/or UB-04 format. The Examiner processes all claims and applicable claims correspondence in accordance with Medicare and Medi-Cal regulatory guidelines, contract provisions and established policies and procedures. Additionally, s/he is responsible for consistently meeting accuracy and productivity targets outlined in the department's performance standards.
SKILLS REQUIRED
- Minimum of 4 years medical claims payment experience in an HMO environment (i.e. MSO, IPA or health plan)
- Strong knowledge of Medicare and Medi-Cal managed care claims processing and compliance guidelines.
- Experience with CPT-4, ICD-10CM, RBRVS, ASA and HCPCS as well as in depth understanding of Medicare and Medi-Cal guidelines that apply to COB and Medicare Secondary Payer.
- Extensive familiarity and experience in plan benefit and co-payment determination, division of financial responsibility determination, claims policies and procedures and adjudication processes and claim review and analysis involving NCCI rules.
- Extensive working knowledge of reimbursement methodologies of professional claims including injectable drugs.
- Must be detail-oriented, attentive, organized, and able to follow directions.
- Ability to work independently utilizing company established processes.
- Ability to meet deadlines and maintain department quality standards.
- Ability to interact well with providers calling regarding claim status.
- Ability to interact well with fellow employees and supervisors and be a team player.
- Strong work ethics and professionalism.
- Intermediate computer skills including Microsoft Word, Excel and Internet navigation.
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