Claims Examiner II/III
2 weeks ago
Job Type
Full-time
Description
We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and/or health plan environment. This position will accurately review, research, and analyze professional claims for a managed service organization (MSO). They will need to be able to work independently and multitask appropriately to make benefit determinations and calculations of type and level of benefit based on established criteria and provider contracts. In-depth knowledge of Health Plans, IPA, and MSO functions, departments, and claims processing procedures are required. This position will need experience in understanding and interpreting fee schedules, eligibility, DOFRs, and contracts, and will assist in identifying and resolving root causes of claim issues.
Position Specs:
- Non-Exempt
- Full-Time
- Benefits-Eligible: PTO, PSL, Holidays, 401(k), Flexible Spending Account, Work/Life Balance, Unpaid Time Off.
- Schedule: Monday - Friday; can discuss scheduling, but typical office hours of 8:30 am - 5:30 pm (your choice of 30 minutes or 60 minutes lunch).
- Salary Range: $24-$37 per hour, depending on experience and knowledge.
Some Major Duties include:
•Identifies authorizations and matches authorization to claims and claim concerns.
•Adjudicate claims in the correct financial banks. Identified dual coverage and potential third-party liability claims. Refers claims with Coordination of Benefits to Management to approve and update system insurance coverage profile.
•Determines out-of-network and out-of-area services or providers and processes in accordance with company and governmental guidelines.
•Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.
•Processes all claims, eligible or ineligible, accurately conforming to quality and production standards and specifications in a timely manner.
•Supports other Examiners in adjudicating claims from payors.
•Adjudication of Commercial, Medicare Advantage, and Medi-Cal claims.
•Documents resolution of claims to support claim payment and/or decisions.
•Demonstrates professional behavior, good business judgement and strong team interaction skills.
•Troubleshoots and resolves inquiries pertaining to Claims Department from internal and external stakeholders.
•Read and interpret provider contracts to ensure payment/denial accuracy.
•Read an interpret Medicare Fee schedules.
•Identifies root causes of claims payment errors and reports any issues pertaining to claims to Management.
•Generates and develops reports which includes but not limited to root causes of provider disputes.
•Collaborates with other departments and/or providers in successful resolution of claims related issues.
•Assist in the creation of business rules and training in order for Claims Department to become more efficient and accurate.
•Attend meetings as needed pertaining to Claims and provide feedback when requested.
•Travelling may be required for check runs - active and valid driver license and car insurance is required.
•Other projects and duties as assigned.
Requirements
EDUCATION
•High School diploma and equivalent work experience in the managed care industry is required.
EXPERIENCE
•3+ years of related claims processing in a managed care organization such as managed service organization, IPA, and/or Health Plan experience.
•Claims processing for Medicare.
•Knowledge in Medicare rules and regulations.
•Knowledge of medical terminology.
•Medi-Cal Claims processing knowledge is a plus.
•Substantial practical knowledge and understanding of relevant business practices and applicable regulations/policies pertaining to Claims processing.
•Knowledge of HCFA 1500 forms, CPT and ICD codes.
•Experience in reading and interpreting DOFRs and Contracts.
•Experience and knowledge in Microsoft Office applications, such as Word and Excel.
SKILLS/KNOWLEDGE/ABILITIES
•Understand division of financial responsibility for determination of financial risk.
•Excellent and effective communication, interpersonal, and organization skills.
•Multitasking skills.
•Ability to be proactive and work independently.
•Excellent written & oral communication skills.
•Excellent computer and typing skills.
•Excellent customer service and conflict resolution abilities.
•Ability to maintain the highest standards of confidentiality and HIPAA.
•Ability to work with a high degree of integrity to perform objective and constructive audits.
•Ability to self-motivate to meet deadlines.
•Cultivate strong working relationships with other internal and external stakeholders.
•Ability to keep track of projects and deadlines, and follow up with any pending issues.
•Ability to accept responsibility and possess the desire to learn new tasks and/or make processes more efficient.
Salary Description
$24 - $37 per hour.
-
Claims Auditor
7 days ago
La Puente, United States Innovative Management Systems, Inc. Full timeJob Type Full-time Description THE POSITION. This position is responsible for reviewing and processing claims, including facility claims, to ensure accuracy prior to payment release. This position is the lead responder to Health Plans and IMS Clients for all products and lines of business. Responsible for management and monitoring of claims compliance with...
-
Accountant II
6 days ago
New Orleans, LA 70123, United States Jefferson Parish Civil Service Full timeJefferson Parish Civil Service is an Equal Opportunity Employer. Purpose of Announcement EXAMINATION IS ANNOUNCED TO SUPPLEMENT THE EXISTING EMPLOYMENT LIST TO FILL ONE (1) CURRENT EAST JEFFERSON VACANCY IN THE DEPARTMENT OF JEFFERSON COMMUNITY ACTION PROGRAMS.This employment list will also be used for future EAST AND WEST Jefferson vacancies in...
-
La Grange, United States PARKS AND WILDLIFE DEPARTMENT Full time**TPWD - Natural Resources Specialist I - II - III (District Biologist)** **(**00041993**)** **Organization**: PARKS AND WILDLIFE DEPARTMENT **Primary Location**: Texas-La Grange **Work Locations**: WL-District 9 111 E. Travis, Suite 200 La Grange 78945 **Job**: Management **Employee Status**: Regular **Schedule**: Full-time **Standard Hours Per...
-
Registered Nurse Per Diem- PACU PreOp
4 days ago
La Puente, United States CEDARS-SINAI Full timeJob Description Make a difference every single day! When the work you do every single day has a crucial impact on the lives of others, every effort, every detail, and every second matters. This shared culture of happiness, passion and dedication pulses through Cedars-Sinai, and it’s just one of the many reasons we’ve achieved our sixth-consecutive...
-
Revenue Cycle Specialist III
2 weeks ago
La Mirada, United States CEDARS-SINAI Full timeJob Description What You Will Be Doing in this Role: Under general supervision and following established practices, policies, and guidelines of Revenue Cycle Management supporting Hospital, Professional Fee billing and collections. Duties include but are not limited to, reviewing and submitting claims to payors, performing account follow-up activities,...
-
Member Services Representative Ii
3 days ago
La Habra, United States Wescom Credit Union Full timeWe value and rely on the unique talents and contributions of our employees to absolutely excel in member engagement by Delivering Signature Experience. Salary Grade: 152N Salary Pay Range for This Position: $22.60 - $31.68 : ESSENTIAL POSITION FUNCTIONS: Consistently provides a high level of service and is committed to increasing member satisfaction by...
-
Full Time General Practice Physician
4 weeks ago
La Junta, United States Northeast Healthcare Recruitment Full timeFlexible Part Time OpportunityGeneral Medicine Physicians (1099) to perform Compensation and Pension Examinations on Veterans, to assist in their VA Benefits Claims. Great Supplemental Income Opportunity.Must be computer savvy and be able to work on their own personal laptop. Should have either experience with, or take it upon themselves to become...
-
Nurse Manager
2 weeks ago
Broussard, LA, United States Frontera Search Partners Full timeWe’re excited to let you know about an opportunity to give back to America’s heroes and help them receive their well-deserved Veterans Affairs (VA) benefits in Broussard, LA.. *Below are a few details about the position:* * Mon - Fri; 8am -5pm * 3-5 Veterans per 8 hour day * $475 per/day * No treating or prescribing * Assessment experience a plus...
-
La Mesa, United States California Department of Education Full timeI. IDENTIFICATION: 1) Referrals for special educational services will go to the resource specialist. The Specialist may process the referrals in any or all of the following ways: a. Confer with the referring teacher b. Notify parents in writing and discuss with them the intended assessment before any testing is done. Obtain written consent from the parent...
-
DELIVERY DRIVER II
1 week ago
Geismar, LA 70734, USA, United States Home Depot Full timeMust reside within a 20-mile radius of Geismar, LASchedule: Monday - Friday; work every other SaturdayPosition Purpose:The Delivery Driver II (CDL A) - Construction Equipment has a CDL A license and operates a tractor-trailer or straight truck to deliver large equipment to DIY and professional customers. This driver is knowledgeable in the basic operation of...
-
Nurse Midwife Opportunity
4 weeks ago
La Porte, IN, United States CHSPSC, LLC. Full timeNorthwest Medical Group , part of Northwest Health Network , has an opportunity for a Certified Nurse Midwife to join busy, well established OB/GYN practice. Experienced practitioners preferred but new grads welcome to apply. Details of Position: Work with collaborative team of nurse midwives and physicians Nurse midwives welcomed by the...
-
Mechanic Helper
3 weeks ago
La Porte, United States Revak Keene Turbomachinery Full timeJob DescriptionJob DescriptionPosition Title: Mechanic Helper Reports To: RTS Foreman I. Broad FunctionAssisting Mechanics to analyze and execute in house and field repairs and upgrades to customer’s machinery. II. Qualification RequirementsA strong hands-on and good working knowledge of the disassembly and assembly of all types of rotating equipment ....
-
Director, Human Resources
2 weeks ago
La Plata, United States University of Maryland Medical System Full timeCompany Description One of the fastest growing counties in Maryland, Charles County is a charming community steeped in culture and history — and University of Maryland Charles Regional Medical Center (UM CRMC) is in the heart of it all. Generations of families have been born in this community hospital and continue to trust the staff with their health and...
-
DELIVERY DRIVER II
2 weeks ago
Baton Rouge, LA 70804, USA, United States Home Depot Full timePosition Purpose:The Rental Delivery Driver II (RDDII) has a CDL-A license and operates a Tractor-Trailer or Straight Truck to deliver Large Equipment to DYI and Professional customers. The driver is knowledgeable in the basic operation of the equipment they deliver and provides basic operational training on the proper and appropriate use to the customer....
-
PATIENT FINANCIAL SERVICES SPECIALIST II
5 days ago
New Iberia, LA 70560, USA, United States IBERIA MEDICAL CENTER Full time:Iberia Medical Center (IMC) in New Iberia, LA is looking for team members who will help advance our vision to be the premier hospital of choice for patients, physicians and employees. We've been caring for our community for over 60 years and offer many diverse career paths. Our new employees experience opportunities to learn and grow while caring for their...
-
Director, Human Resources
4 weeks ago
La Plata, United States University of Maryland Medical System Full timeJob DescriptionJob DescriptionCompany DescriptionOne of the fastest growing counties in Maryland, Charles County is a charming community steeped in culture and history — and University of Maryland Charles Regional Medical Center (UM CRMC) is in the heart of it all. Generations of families have been born in this community hospital and continue to trust the...
-
La Quinta, United States Pyramid Global Hospitality Full timeProperty About Us At Pyramid Global Hospitality, people come first. As a company that values its employees, Pyramid Global Hospitality is dedicated to creating a supportive and inclusive work environment that fosters diversity, growth, development, and wellbeing. Our commitment to a People First culture is reflected in our approach to employee development,...
-
RESEARCH NURSE
3 weeks ago
New Orleans, LA 70130, USA, United States Tulane University Full timeThis is a nursing research position. Training will be provided to develop the necessary skills required of a research nurse. The primary responsibility of the Research Nurse is to manage RN responsibilities in the conduct of clinical trials. This position also requires management of global oncology research within the Hematology/Oncology department. The...
-
Instrumentation Engineer
4 weeks ago
La Porte, United States Kelly Science, Engineering, Technology & Telecom Full timeArea Instrumentation EngineerLocation: La Porte, IN (Relocation assistance available)Pay: $120,000 to $140,000 (Depending upon experience)QualificationsEducation/Experience Requirements• Bachelor’s Degree in relevant Engineering Discipline required• 5 to 7 years of experience with at least 5 years in an operational and engineering environment working...
-
Instrumentation Engineer
4 weeks ago
La Porte, United States Kelly Science, Engineering, Technology & Telecom Full timeArea Instrumentation EngineerLocation: La Porte, IN (Relocation assistance available)Pay: $120,000 to $140,000 (Depending upon experience)QualificationsEducation/Experience Requirements• Bachelor’s Degree in relevant Engineering Discipline required• 5 to 7 years of experience with at least 5 years in an operational and engineering environment working...
