The Claims Examiner’s duties and responsibilities are to adjudicate both hospital and professional claims in an efficient, cost-effective and timely manner. Responsible for determining financial responsibility between group, health plans and contracted hospitals for accurate processing of claims.
Essential Responsibilities:
The following are essential job duties and responsibilities and are not intended to represent an all-inclusive listing of related essential functions of the position:
- Interprets contract coverage for medical HMO claims.
- 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.
- Strong working knowledge of Medicare and Medi-Cal,
- 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.
- Prepares claims for medical review and signature review per processing guidelines.
- Identify correct 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 on line tools used to process claims
- Good knowledge of CPT/HCPCS/ICD-10, and Revenue Codes, including modifiers.
- Researches authorizations and properly selects appropriate authorization for services billed.
Qualifications:
- 1 year claims processing experience, preferably in an IPA or Medical Group.
- Knowledge of managed care claims processing and compliance.
- Proficient in CPT, HCPCS, ASA and ICD-9 coding.
- 10-Key by touch.
- EZ-CAP experience preferred
Job Type: Full-time
Pay: $17.00 - $21.00 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
Work Location: In person
