Claims Examiner I
3 days 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 assignedQUALIFICATION 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.
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Claims Examiner
4 weeks ago
Orange, United States California Staffing Full timeClaims ExaminerWe're seeking an experienced Claims Examiner for a hybrid role in Orange, CA. The ideal candidate will analyze and manage complex workers' compensation claims, ensuring timely resolution and adherence to best practices. You'll handle high-exposure cases involving litigation, rehabilitation, and settlement negotiations, while maintaining...
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Claims Examiner I
2 weeks ago
Orange, CA, United States Astiva Health, Inc Full timeAbout 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...
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Claims Examiner I
1 week ago
Orange, CA, United States Astiva Health, Inc Full timeAbout 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...
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Claims Examiner I
1 week ago
Orange, CA, United States Astiva Health, Inc Full timeAbout 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...
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Claims Examiner I
1 week ago
Orange, CA, United States Astiva Health, Inc Full timeAbout 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...
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Senior Claims Examiner
23 hours ago
Orange, United States ATHENS ADMINISTRATORS Full timeATHENS POSITION DETAILS Position Title: Senior Claims Examiner Department: Workers’ Compensation California Reports To: Claims Supervisor FLSA Status: Non-Exempt Job Grade: 12 Career Ladder: Next step in progression could include Lead Senior Claims Examiner or Claims Supervisor ATHENS ADMINISTRATORS Explore the Athens Administrators difference: We have...
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Senior Claims Examiner
7 days ago
Orange, United States ATHENS ADMINISTRATORS Full timeATHENS POSITION DETAILS Position Title: Senior Claims Examiner Department: Workers’ Compensation California Reports To: Claims Supervisor FLSA Status: Non-Exempt Job Grade: 12 Career Ladder: Next step in progression could include Lead Senior Claims Examiner or Claims Supervisor ATHENS ADMINISTRATORS Explore the Athens Administrators difference: We have...
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Claims Examiner Sr
7 days ago
Orange, United States CalOptima Full timeClaims Examiner SrCalOptimaJoin Us in this Amazing OpportunityThe Team You'll JoinWe are a mission driven community‐based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us...
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Claims Examiner II
2 days ago
Orange, California, United States Athens Administrators Full time $60,000 - $120,000 per yearATHENS POSITION DETAILSPosition Title:Claims Examiner IIDepartment:Property & CasualtyReports To:Claims Supervisor P&CFLSA Status:Non-Exempt in CaliforniaJob Grade:11Career LadderNext step in progression could include Senior Claims ExaminerATHENS ADMINISTRATORSExplore the Athens Administrators difference: We have been dynamic, innovative leaders in claims...
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Claims Examiner Sr
4 weeks ago
Orange, United States Government Jobs Full timeClaims Examiner SrJoin Us in this Amazing OpportunityWe are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities...
