Claims Examiner I
2 weeks ago
About Us: Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.
SUMMARY: Under the direction of the Vice President of Claims, this position is responsible for manual input and adjudication of claims submitted to the health plan. The ideal candidate will need to interpret and utilize capitation contracts, payor matrixes, subscriber benefit plan, and provider contracts; as well as resolving customer service inquiries, status calls, andclaim tracers.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:
Data enter paper claims into EZCAP.
Review and interpret provider contracts to properly adjudicate claims.
Review and interpret Division of Financial Responsibility (DOFR) for claims processing.
Perform delegated duties in a timely and efficient manner. Verify eligibility and benefits as necessary to properly apply co-pays.
Understands eligibility, enrollment, and authorization process. Knowledge of prompt payment guidelines for clean and unclean claims
Process claims efficiently and maintains acceptable quality of at least 95% on reviewed claims.
Meets daily production standards set for the department.
Prepares claims for medical review and signature review per processing guidelines.
Identify the correctly received date on claims, with knowledge of all time frames for meeting compliance for all lines of business.
Maintains good working knowledge of system/internet and online tools used to process claims
Good knowledge of CPT/HCPCS/ICD-10, and Revenue Codes, including modifiers.
Assist customer service as needed to assist in claims resolution on calls from providers.
Research authorizations and properly selects appropriate authorization for services billed.
Coordinate with the claims clerks on issues related to the submission and forwarding of claims determined to be financial responsibility of another organization.
Coordinate Benefits on claims for which member has another primary coverage
Run monthly reports.
Review pre and post check run.
Regular and consistent attendance
Other duties as assigned
QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE:
High School Diploma or GED required.
1 to 3 years of previous experience in a health plan, IPA or medical group.
Strong understanding of the benefit process including member services or customer service.
Demonstrated proficiency in MS Office (Excel, Word, Outlook, and PowerPoint).
Able to navigate difficult situations with empathy, discretion, and professionalism.
Strong understanding of Senior Medicare Advantage Health plans.
Able to explain member benefits, answer questions and concerns using a Customer Service First attitude.
Able to live our mission, vision, and values,
Bilingual in another language (written and oral) preferred.
-
Claims Examiner
2 weeks ago
Orange, CA, United States BCforward Full timeClaims Examiner - Workers Compensation BC Forward is looking for Claims Examiner - Workers Compensation in Orange, CA 92868 Position Title: Claims Examiner - Workers Compensation Locations: 333 City Boulevard West, Orange, CA 92868 Anticipated Start Date: 11/03 Expected Duration: 2+ Months Job Type: Contract with possible extension Pay Rate $47.00/hr. on...
-
Liability Claims Examiner
2 weeks ago
Orange, CA, United States Sedgwick Full timeBy joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there's no limit to what you can achieve. Newsweek Recognizes Sedgwick as...
-
Liability Claims Examiner
1 week ago
Orange, CA, United States Sedgwick Full timeBy joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there's no limit to what you can achieve. Newsweek Recognizes Sedgwick as...
-
Claims Examiner
1 week ago
Orange, CA, United States TAJ Technologies Inc Full timeDescription: Min 3 years of experience Remote in CA - Candidate has to be in CA PRIMARY PURPOSE: To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best...
-
Claims Examiner
2 weeks ago
Orange, CA, United States Synectics Full timeDescription : To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of...
-
Sr. Claims Specialist
4 days ago
Orange, CA, United States Cooperative of American Physicians Full timeCAP seeks a Senior Claims Specialist for its Orange County office. This role involves handling technical and administrative duties to manage assigned claim files; assumes increased workload of highly complex claims. The Senior Claims Specialist also plays an active role in the ongoing training and oversight of Claims Specialist I and II team members.Our...
-
Orange, CA, United States Sedgwick Full timeBy joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as...
-
Orange, CA, United States Sedgwick Full timeBy joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as...
-
Nurse Practitioner I
7 hours ago
Orange, CA, United States University of California Full timeWho We Are Founded in 1965, UC Irvine is a member of the prestigious Association of American Universities and is ranked among the nation's top 10 public universities by U.S. News & World Report. The campus has produced five Nobel laureates and is known for its academic achievement, premier research, innovation and anteater mascot. Led by Chancellor Howard...
-
Travel Pediatric Intensive Care Unit RN
1 week ago
Orange, CA, United States Travel Nurse Across America Full timeWe're looking for Pediatric Intensive Care Unit RNs for an immediate travel nurse opening in Orange, CA. The right RN should have 1-2 years' recent acute care experience. Read below for more requirements. As a PICU RN, you'll provide critical care to pediatric patients as part of a broader medical team. You will collaborate with physicians, specialists and...
