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Claims Examiner
4 months ago
**Job Summary**:
Through comprehensive assessment and analysis, adjudicates managed healthcare claims/bills, authorizations and referrals, for payment or denial within contract agreement and/or regulatory requirements. Performs these duties using industry standard knowledge of managed healthcare claim/bill payment processing and medical regulations, verifies and updates relevant data into various computerized internal and external systems.
**Essential Responsibilities**:
- For all lines of business, including MMA, Part D, analyze claim holds/pends, research and track required claim information to adjudicate professional and hospital claims/bills.
- Proactively communicate with internal departments as appropriate to resolve claims issues promptly.
- Provies input to supervisor and Training and Development team regarding training and educational tools to enhance department production and processes.
- Provides assistance to prepare materials as needed to leads, supervisors, and managers for external audits.
- Communicate problems and/or trends to leads and management.
- Other duties as assigned within the job functions
**Basic Qualifications**:
Experience
- Minimum two (2) years claims adjudication experience or two (2) years of internal claims (encounter) processing experience.
Education
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- N/A
**Additional Requirements**:
- Must be able to work in a Labor Management Partnership environment
- Knowledge of medical terminology and international classification of Disease (ICD-10) and Current Procedure Terminology (CPT)
- Basic PC skills
- Ability to do basic math (addition, subtraction, multiplication)
- Ability to understand and meet customer needs in a claims setting
- Attention to detail
**Preferred Qualifications**:
- Working knowledge of Microsoft Excel preferred
PrimaryLocation : California,Oakland,1800 Harrison
HoursPerWeek : 40
Shift : Day
Workdays : Mon-Fri
WorkingHoursStart : 08:00 AM
WorkingHoursEnd : 04:30 PM
Job Schedule : Full-time
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : A04|OPEIU|Local 29
Job Level : Entry Level
Job Category : Insurance & Claims
Department : Oakland Reg - 1800 Harrison - NCA Ongoing Operating Exp - 0208
Travel : No