Medical Claims Examiner
4 weeks ago
The Claims Examiner position is a critical role within our organization, responsible for ensuring the accurate and timely adjudication of paper and/or electronically formatted claims received in the CMS 1500 and/or UB-04 format.
Key Responsibilities:
- Process all claims and applicable claims correspondence in accordance with Medicare and Medi-Cal regulatory guidelines, contract provisions, and established policies and procedures.
- Consistently meet accuracy and productivity targets outlined in the department's performance standards.
- Utilize strong knowledge of Medicare and Medi-Cal managed care claims processing and compliance guidelines to ensure accurate claims adjudication.
- Collaborate with providers to resolve claim status inquiries and provide excellent customer service.
- Stay up-to-date with changing regulations and guidelines to ensure compliance and accuracy in claims processing.
Requirements:
- Minimum of 4 years medical claims payment experience in an HMO environment (i.e. MSO, IPA, or health plan).
- Strong knowledge of CPT-4, ICD-10CM, RBRVS, ASA, and HCPCS, as well as in-depth understanding of Medicare and Medi-Cal guidelines that apply to COB and Medicare Secondary Payer.
- Extensive familiarity and experience in plan benefit and co-payment determination, division of financial responsibility determination, claims policies and procedures, and adjudication processes and claim review and analysis involving NCCI rules.
- Extensive working knowledge of reimbursement methodologies of professional claims, including injectable drugs.
- Must be detail-oriented, attentive, organized, and able to follow directions.
- Ability to work independently utilizing company-established processes.
- Ability to meet deadlines and maintain department quality standards.
- Ability to interact well with providers, fellow employees, and supervisors, and be a team player.
- Strong work ethics and professionalism.
- Intermediate computer skills, including Microsoft Word, Excel, and Internet navigation.
About Thrifty Management Services:
Thrifty Management Services is the dedicated MSO for Preferred IPA of California, providing the best possible care management, care coordination, and claims processing services to Preferred IPA and their members. We work with the network's participating physicians to coordinate patient care when a referral is made to a specialist or hospital for diagnosis and treatment. We coordinate patient care across all aspects of the provider network, providing high-quality services to our participating physicians and superior healthcare to our members.
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