Claims Examiner

1 week ago


Whittier, CA, United States vTech Solution Full time

Job Summary:

The Claims Examiner is responsible for processing UB-92 and HCFA-1500 claims from affiliated medical groups and hospitals for HMO patients. This includes operation, adjudication, and payment functions, reporting directly to the claims manager.

Location:Whittier, California, United States

Responsibilities:

- Process UB-92 and HCFA-1500 claims.
- Perform claims adjudication and payment.
- Identify non-contracted providers for Letter of Agreement consideration.
- Data entry.
- Interpret provider contract reimbursement terms.
- Maintain knowledge of compliance issues related to claims processing.
- Understand timeliness and payment accuracy guidelines for commercial, senior, and Medi-Cal claims.

Required Skills & Certifications:

- High school diploma or GED equivalent.
- Minimum 2 years of claims adjudication experience in ambulatory, acute care hospital, HMO, or IPA environment.
- Knowledge of payment methodologies for Professional (MD), Hospital, Skilled Nursing Facilities, and Ancillary Services.
- Claims reimbursement experience.
- DOFR (Date of First Receipt) experience.
- Experience processing lab claims.

Preferred Skills & Certifications:

- Experience interpreting provider contract reimbursement terms.

Special Considerations:

- Onsite interview required.
- RTO (Requested Time Off) must be submitted at the time of submittal.

Scheduling:
- Monday - Friday
- 07:00am - 03:30pm
- Orientation time may differ from shift times listed.
- Duration: 13 weeks


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