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Claims Examiner Iii
4 months ago
**Claims Examiner III**
**Role Insights**
**Primary Responsibilities**
- Audit claims processing quality, develops, maintains and runs standard reports
- Assist the Claims Supervisor/Director in reviewing the quality auditing tracking/reporting (financial and procedural)
- Coordinating with various departments to resolve disputes or issues
- Maintain the Claims department workflow
- Review and process hospital claims and complicated claims to assist claims examiners I, and II
- Claims processing to ensure quality (in/out patient hospital claims, Medi-Cal, Commercial, and Medi-care claims)
- Review auto adjudication of claims
- Review carve-outs in the Division of Financial Responsibility (DOFR)
- Review and process reports and work with management and claims unit
- Assist the Claims Manager in reviewing the quality auditing tracking/reporting
- Assist with training/supporting the claims team
- Recommend and assist in the development of process improvements
- Coordinating with various departments to resolve disputes or issues
- Able to process a claim and assist the team by answering questions and providing support
- Prepare for check runs
- Other duties may be assigned as needed to assist the AMM team
**Required Skills and Abilities**
- High School Diploma or GED, some college preferred
- 3-5 yrs of claims examiner experience processing professional and facility claims
- Strong analytical skills and problem solving skills are necessary
- Know the industry guidelines for all LOBs
- Proficient with medical terminology, CPT, Revenue codes, ICD-10,
- Medicare and Medi-Cal claims adjudication experience required
- Knowledge of claims processing rules, managed care benefits and adjudication
- Strong analytical skills and problem-solving skills are necessary
- Familiarity with Medicare guidelines and ICE compliance guidelines
- Experience with the handling of claims in a managed care business (HMO)
- Extensive knowledge of claims processing and claims data analysis
- Experience with EZ-Cap and Encoder Pro preferred
- Must be familiar with Microsoft Office (Word, Excel, Outlook)
- Must possess a positive attitude, have excellent communication skills and is able to meet deadlines in a fast-paced environment
- Must work well under pressure and deadlines
**AAP/EEO Statement**
Pay: $23.00 - $30.00 per hour
**Benefits**:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Referral program
- Tuition reimbursement
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
- No weekends
Work setting:
- In-person
- Office
**Experience**:
- claims examiner: 3 years (required)
- Medical terminology: 1 year (required)
- claims processing: 1 year (required)
Work Location: In person
