Claims Examiner II- Bakersfield

Claims Examiner II

Location: Bakersfield, CA. (Onsite)

Classification: Full-Time

This position is non-exempt and will be paid on an hourly basis.

Schedule: Monday-Friday 8am-5pm

Benefits:

• Medical
• Dental
• Vision
• Paid Time Off (PTO)
• Floating Holiday
• Simple IRA Plan with a 3% Employer Contribution
• Employer Paid Life Insurance
• Employee Assistance Program

Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $21.40 and $26.74. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

Position Summary:

As the Claims Examiner II, your primary responsibility will be to adjudicate medical claims within claims transaction system. Verifying information is accurately captured and complete in database. You will process both professional (CMS 1500) and institutional (CMS 1450/UB04). During this verification process, the system will prompt you to conduct audits on specific fields to ensure accuracy and completeness for each claim in the batch.

Job Duties and Responsibilities:

• Follow written criteria, policies, and procedures to thoroughly review and process claim.
• Evaluate claims for appropriateness of payment, considering factors such as eligibility, benefits, authorizations, coding, compliance, contracted payment terms or relevant fee schedule, and health plan contracts.
• Stay informed about annual changes in contracts and apply the correct terms to claims, ensuring adherence to contracted payment terms and health plan agreements.
• Ensure accurate and proper denial processing in the system for claims deemed inappropriate for payment, facilitating correct letter generation.
• Consistently meet internal, external, and governmental timeliness standards in processing claims to ensure prompt and efficient service delivery.
• Exercise the freedom to make decisions regarding payment or denial of medical services, handling sensitive and confidential information with utmost discretion.
• Refer claims and accompanying documentation to the Utilization Management (UM) department if they do not align with department policy guidelines.
• Interact with various stakeholders, including Eligibility, Member Services, UM, providers, Health Plans, and applicable staff, as needed for claim resolution.
• Maintain compliance with established production and quality standards, ensuring accuracy and efficiency in claim processing.
• Work independently on assigned tasks and activities based on established policies and procedures, demonstrating autonomy and accountability.
• Other related duties as assigned.

Qualifications:

• High School diploma or equivalent.
• Strong knowledge of professional and institutional claim processing procedures, including COB (Coordination of Benefits)/TPL (Third Party Liability)/WC.
• Familiarity with CPT, HCPCS, ICD-10, ASA, Revenue Codes, etc.
• Performs high volume data entry.
• Strong background with system automation of claims processes and workflows.
• Familiar with office equipment (including a photocopy machine, scanner, facsimile machine, etc.)
• Proficiency in MS Excel, Word, and Outlook.
• Ability to type 40-50 Words per minute (WPM) or 6,000 8,000 Keystrokes per Hour (KSPH).
• One or more years working in a healthcare or other related business environment: experience in medical billing services and/or managed care environment preferred.

Other Requirements:

• Possession of a valid driver's license.
• Proof of state-required auto liability insurance