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Claims Examiner III
2 months ago
**Role Overview**
The Claims Examiner III is a critical position within the Advanced Medical Manage organization, playing a vital role in the Claims Department. This role requires collaboration with the Claims Team to meet productivity goals and ensure quality. The ideal candidate will possess claims knowledge, prioritization skills, and the ability to multitask in a fast-paced environment.
**Key Responsibilities**
- Audit Claims Processing Quality: Develop, maintain, and run standard reports to ensure compliance and efficiency.
- Assist in Quality Auditing Tracking/Reporting: Collaborate with the Claims Supervisor/Director to review and analyze quality auditing data.
- Resolve Disputes and Issues: Coordinate with various departments to resolve claims-related disputes and issues.
- Maintain Claims Department Workflow: Ensure seamless claims processing and management.
- Review and Process Hospital Claims: Assist Claims Examiners I and II in reviewing and processing hospital claims, including inpatient and outpatient claims, Medi-cal, Commercial, and Medi-care claims.
- Claims Processing and Quality Assurance: Ensure quality claims processing, including auto adjudication of claims and review of carve-outs in the Division of Financial Responsibility (DOFR).
- Report Preparation and Management: Prepare and review reports, working closely with management and the claims unit.
- Training and Support: Assist in training and supporting the claims team, recommending process improvements, and coordinating with various departments to resolve disputes or issues.
- Additional Responsibilities: Process claims, answer questions, and provide support to the team, prepare for check runs, and perform other duties as assigned to assist the AMM team.
**Required Skills and Abilities**
- Education: High School Diploma or GED, some college preferred.
- Experience: 3-5 years of claims examiner experience processing professional and facility claims.
- Analytical and Problem-Solving Skills: Strong analytical skills and problem-solving skills are necessary for this role.
- Industry Knowledge: Knowledge of industry guidelines for all Lines of Business (LOBs).
- Medical Terminology and Coding: Proficient with medical terminology, CPT, Revenue codes, ICD-10, Medicare, and Medi-Cal claims adjudication experience required.
- Claims Processing Rules and Managed Care Benefits: Knowledge of claims processing rules, managed care benefits, and adjudication.
- Microsoft Office Skills: Familiarity with Microsoft Office (Word, Excel, Outlook) and ability to meet deadlines in a fast-paced environment.
- Positive Attitude and Communication Skills: Must possess a positive attitude, excellent communication skills, and ability to work well under pressure and deadlines.
