Lead Claims Examiner

To evaluate and determine the appropriate path and to assist in the expedited processing of all claims, special projects and escalated reconsiderations originating from various internal and external sources and to serve as the first level of telephonic and written response for such issues. Responsibilities Maintain the workflow of all departmental projects. Provide reports and ongoing updates to Claims management. Assist in the processing of claims, special projects and medical records from all sources. Oversee staff activities to maintain a high level of productivity. Monitor claims-related functions to ensure health plan and regulatory compliance. Participate with training determined by unit Supervisor regarding claims adjudication issues discovered in audit or through appeals. Perform audits of claims activities such as turnaround time for acknowledgement, forwarding of claims to correct payer, and processing timeframes. Provide primary support to the Supervisor of the Institutional unit including special projects. Recommend process improvements based on appeal tracking and trending reports. Support Claims management in other company functions such as Medical Review management. Handle and document resolution to escalated telephone and written claims. Implement and coordinate issue resolution processes. Liaison for department with outside providers and internal departments. Provide supervisory coverage for Claims unit as needed. All other duties as directed by management. The pay range for this position at commencement of employment is expected to be between $28-$30 per hour ; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience. The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered. Details of participation in these benefit plans will be provided if an employee receives an offer of employment. If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors. Benefits Employer-paid comprehensive medical, pharmacy, and dental for employees Vision insurance Zero co-payments for employed physician office visits Flexible Spending Account (FSA) Employer-Paid Life Insurance Employee Assistance Program (EAP) Behavioral Health Services 401(k) Retirement Savings Plan Income Protection Insurance Vacation Time Company celebrations Employee Referral Bonus Tuition Reimbursement License Renewal CEU Cost Reimbursement Program Business-casual working environment Sick days Paid holidays Mileage Qualifications High School Diploma and 3 years adjudication experience in a managed care setting. Knowledge of CPT-4, HCPCS, Hospital Revenue, and ICD-9 coding. Knowledge of HMO, DHS, DMHC, and CMS claims processing guidelines. Strong knowledge of Microsoft Windows environment such as Word and Excel. Self-starter, willing to take on multiple tasks. Must meet minimal claims adjudication production standards. Strong knowledge of Coordination of Benefits (COB) applications. Must be able to interpret health plan benefits. Must be able to review, interpret and apply contract rates. Ability to communicate effectively orally and written typing 35 words per minute. Strong organizational skills with emphasis on prioritizing and attention to details. Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance. #J-18808-Ljbffr