Medical Claims Processor

Description Adjusts and adjudicates multiple lines of business in a timely manner to ensure compliance with departmental and regulatory turn‑around time and quality standards. Reviews claims and makes payment/adjustment determinations to ensure all components—member, provider, authorization, claim, and system—are valid and correct for accurate processing. Conducts research regarding claim completion and appropriateness; identifies errors and takes necessary actions to resolve claims. Manages work to meet regulatory guidelines. Essential Functions Review claims and make payment determinations. Evaluate claims for proper and correct information, including member, provider, authorization, and billing details. Refer to eligibility, authorization, benefit, and pricing information to determine appropriate action (e.g., claim reject/denial, request for additional information). Research coordination of benefit issues, fraud and abuse, and third‑party liability. Apply knowledge of government regulatory policies and procedures to ensure compliance with CMS, DHMC, DOC, DHS, and accrediting agencies such as NCQA. Prepare material for audits and assist Lead and Supervisor during audit activities. Work with Lead and Supervisor on claim reporting requirements. Review member/provider claims by checking provider service contracts and supporting documentation in accordance with service agreements. Coordinate payment agreements with providers. Proactively ensure claim reviews are resolved appropriately. Qualifications Basic Qualifications One (1) year of medical claim adjudication experience. Experience processing multiple types of medical claims and lines of business. Problem‑solving skills; ability to systematically analyze problems and devise appropriate courses of action. Excellent verbal and written communication skills; ability to convey complex information clearly. Intermediate computer skills—proficiency with Microsoft Word, Outlook, and Internet Explorer, and familiarity with a Windows environment. Additional Requirements Knowledge of claims processing regulatory guidelines (HIPAA, Timelines Standards, Medical Terminology, etc.). Knowledge of various payment methodologies and government reimbursement guidelines. Knowledge of claims categorization/codification guidelines (Revenue Codes, Occurrence & Condition Codes, CPT/HCPCS codes, ICD‑10 Diagnosis & Procedure Codes). Must have basic PC skills. Related experience in Medical Claims. Working knowledge of CPT, ICD‑10, Medical Terminology, COB/TPL/WC. Must work effectively in a fast‑paced environment. Preferred Qualifications Experience with in‑patient claims processing. Medical Terminology Certificate preferred. Job Type Full‑time Monday–Friday 8:30 am – 5:30 pm 1‑hour lunch break Required Education High school or equivalent Required Experience Medical Claims Processing: 1 year Benefits Dental insurance Health insurance Paid time off Vision insurance Application Question(s) Do you have medical terminology experience? If so, how long? Ability to Commute Buena Park, CA 90620 (Required) Work Location In person Resume Submission Contact: View email address on click.appcast.io #J-18808-Ljbffr