Medical Claims Examiner

4 days ago


Fountain Valley, California, United States MemorialCare Health System Full time

Job Summary:

As a Claims Examiner II at MemorialCare Health System, you will play a critical role in ensuring the accuracy and efficiency of our claims processing operations. This position requires a highly skilled and detail-oriented individual with a strong understanding of healthcare claims and regulations.

Key Responsibilities:

  • Review and analyze professional, ancillary, and institutional claims for accuracy and compliance with DMHC and CMS guidelines.
  • Comprehensive knowledge of various fee schedules and CMS prices for professional, facility, and ancillary claims.
  • Ability to identify and report processing inaccuracies related to system configuration.
  • Process all types of claims, including HCFA 1500, outpatient/inpatient UB92, high-dollar claims, COB, and DRG claims.
  • Adjudicate claims for payment accuracy or denial of payment according to Department's policy and procedures.
  • Document resolution of claims to support claim payment and/or decision.
  • Understand and interpret health plan Division of Financial Responsibilities and contract verbiage.
  • Determine out-of-network and out-of-area services providers and process in accordance with company and governmental guidelines.
  • Ability to prioritize, multitask, and manage claims assignment within department goals and regulatory compliance with minimal supervision.
  • Ability to effectively communicate with External and Internal teams to resolve claims issues.

Requirements:

  • Minimum of 5+ years' experience in processing all types of professional, ancillary, and institutional claims in Managed Care.
  • Comprehensive knowledge of CPT, ICD-9, and ICD-10 codes, inpatient procedure coding, HCPCS, Revenue Codes, medical terminology, and COB.
  • Working knowledge of Claims Information systems.
  • Understanding of division of financial responsibility for determination of financial risk.

About MemorialCare Health System:

MemorialCare Health System is a nonprofit integrated health system that includes four leading hospitals, award-winning medical groups, and more than 2,000 physicians throughout Orange and Los Angeles Counties. We are committed to increasing access to patient-centric, affordable, and high-quality healthcare, and your personal contributions are integral to our recognition as a market leader and innovator in value-based and other care models.


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