Claims Assessment Specialist

2 weeks ago

Montebello, California, United States North American Staffing Group Full time
Job Overview

Position Type: Direct Hire

Location: Montebello, CA (Hybrid after initial training onsite is completed)

Hourly Rate: $24 - $30/HR based on experience

Available Schedules: 6AM - 3PM, 7AM - 4PM, 8AM - 5PM

Job Responsibilities
  • Evaluate and adjudicate medical claims in accordance with managed care protocols.
  • Conduct payment reconciliations and adjustments linked to retroactive contract modifications and fee schedule updates.
  • Address claims payment discrepancies through the Provider Dispute Resolution (PDR) process and respond to inquiries regarding claims incidents.
  • Identify underlying causes of claims payment inaccuracies and report findings to management.
  • Generate and compile reports detailing root causes of PDRs and incidents.
  • Collaborate with various departments and providers to effectively resolve claims-related challenges.
Key Duties
  • Process medical claims, both professional and institutional, ensuring compliance with relevant Federal and State regulations based on the member's Line of Business.
  • Interpret and analyze DOFRs to confirm financial risk for payment.
  • Review provider contracts to ensure accuracy in payment and denial processes.
  • Understand and apply Medi-Cal and Medicare Fee Schedules.
  • Rectify claims payment or denial errors identified by the Claims Auditor prior to payment runs.
  • Maintain an error accuracy rate of under 3%.
  • Communicate effectively with Claims Management regarding provider, fee schedule, eligibility, authorization, or system-related issues.
  • Assist in developing business rules and training to enhance the efficiency and accuracy of the Claims Department.
  • Coordinate with the Recovery Department on any detected overpayments.
  • Participate in monthly departmental meetings and provide constructive feedback as needed.
  • Perform additional duties as assigned.
Qualifications
  • High School Diploma or GED required.
  • Minimum of 2 years of claims processing experience in a managed care setting.
  • Knowledge of Medi-Cal regulations is essential.
  • Preferred familiarity with Medicare and Commercial rules and regulations.
  • Understanding of medical terminology is necessary.
  • Ability to read and interpret DOFRs and contracts.
  • Proficiency in reading CMS-1500 and UB-04 forms.
  • Strong organizational and mathematical skills are required.

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