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Claims Assessment Specialist
2 months ago
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
Key Responsibilities- Evaluate and adjudicate medical claims in accordance with managed care protocols.
- Conduct payment reconciliations and adjustments due to retroactive contract rate changes.
- Address claims payment discrepancies through the Provider Dispute Resolution (PDR) process.
- Identify and report root causes of claims payment errors to management.
- Respond to provider inquiries regarding claims payments.
- Generate comprehensive reports detailing root causes of PDRs and incidents.
- Collaborate with various departments and providers to resolve claims-related issues.
- High School Diploma or GED required.
- Minimum of 2 years of claims processing experience in a managed care setting.
- Familiarity with Medi-Cal regulations is essential.
- Preferred knowledge of Medicare and Commercial insurance rules.
- Understanding of medical terminology is necessary.
- Ability to read and interpret DOFRs and provider contracts.
- Proficiency in understanding CMS-1500 and UB-04 forms.
- Strong organizational and mathematical skills are required.
- Maintain an error accuracy rate of under 3%.
- Communicate effectively with Claims Management regarding provider, fee schedule, eligibility, and authorization issues.
- Assist in developing business rules and training to enhance departmental efficiency.
- Coordinate with the Recovery Department to address any identified overpayments.
- Participate in monthly departmental meetings and provide constructive feedback.
- Perform additional duties as assigned.
