Claims Examiner

1 week ago

Fountain Valley, United States MemorialCare Medical Foundation Full time

**Claims Examiner**
- (MEM008006)

**Description**

**Title**: Claims Examiner

**Location**: Fountain Valley

**Department**: Claims

**Status**: Full-Time

**Shift**: Days (8hrs)

**Pay Range**:$21.37/hr - $30.97/hr

At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. Memorial Care stands for excellence in healthcare. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.

**Purpose Statement / Position Summary**

The Claims Examiner I accurately review, researches and analyzes professional claims. Makes benefit determinations and calculations of type and level of benefit based on established criteria and provider contracts.

**Essential Functions and Responsibilities of the Job**
- Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines.
- Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims.
- Process HCFA 1500s and COB claims.
- Reviews, processes and adjudicate claims for payment accuracy or denial of payment according to Department’s policy and procedures.
- Processes all claims accurately conforming to quality and production standards and specifications in a timely manner.
- Documents resolution of claims to support claim payment and/or decisions appropriately.
- Makes benefit determinations and calculations of type and level of benefits based on established criteria and provider contracts.
- Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.
- Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines.
- Adjudication of Commercial and Medicare Advantage claims.
- Ability to prioritize, multitask and manage claims assignment within department goals and regulatory compliance and with mínimal supervision.
- Ability to make phone calls to Provider/Billing offices, when necessary, based on department guidelines.
- Requests additional information or follow up with provider for incomplete or unclean claims.
- Ability to effectively communicate with External and Internal teams to resolve claims issues.
- Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. _Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there’s more..._Check out our _MemorialCare Benefits _for more information about our Benefits and Rewards_

**Qualifications**

**Experience**
- Ten keys by touch.
- Type a minimum of 45 words per minute.
- Basic claims processing knowledge.
- Able to recognize CMS 1500 and UB 04 forms.
- Basic knowledge of CPT, ICD-9 codes and ICD-10 codes.
- Understands division of financial responsibility for determination of financial risk.
- Demonstrate effective communication, interpersonal, and organizational skills.
- Excellent written & oral communication skills.
- Ability to follow instructions.

**Education**

High School Diploma

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