Claims Examiner I

Found in: Talent US C2 - 2 weeks ago

Monterey Park, United States ApolloMed Full time

About the Role

: We are currently seeking a highly motivated Claims Examiner. This role will report to the Manager - Claims and enable us to continue to scale in the healthcare industry. What You'll Do:  Performs through review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services Processes non-institutional claim types for all line of business (Medicare, Medical, Commercial, etc) The Specialist should clearly understand the products and healthcare benefits services offered to customers, including cost share, limits and regulatory rules and guidelines Configure provider contracts, Fee schedule updates and other documents Develop configuration testing & validate accuracy of data loaded Communicated required system updates to Provider Contracting & Claims operations Coordinate research & resolution of debarred & sanctioned providers Corrects system generated errors manually prior to final claims adjudication Communicated required system updates to Provider Contracting & Claims operations Process claims based upon the provider’s contract/agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and NMM policies and procedures Analyzes and validates Medi-cal pricing researches, Adjusts and adjudicates claims reviews services for accurate charges and utilizes current billing code sets, ( International Classification Diseases (ICD 10) Codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference Validates eligibility and other possible health insurance coverage on the claims ( Medicare primary, California Children services (CCS),,) Alerts manager or supervisor of more complex issues that arise Processes claim exception reports as assigned Recognize claim correspondences from multiple IPAs Recognize the health plan financial risk (Division of Financial Responsibility) Recognize the difference between Shared Risk and Full Risk claims Maintain required levels of production and quality standards as established by management Attendance at employer worksite is an essential job requirement Work assigned claim project to completion Contribute to team effort by accomplishing related results as needed Qualifications:  Knowledge of MS Word, Excel and basic medical terminology High School graduate or equivalent requires EZ-CAP knowledge; or equivalent combination of education and experience Excellent knowledge of CPT, HCPCS, ICD-10 CM, ICD-10 PCS, etc Typing speed 70+ WPM and knowledge of 10 key desired Ability to multi-task and meet deadlines Strong organization skills; ability to multitask and properly manage time Position may require unscheduled overtime, week-end work Ability to understand work with proprietary software applications Organizational ability and ability to exercise good judgment Work independently as part of a team At least 2 year plus of claims processing experience in the health insurance industry or medical health care delivery system

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