Claims Examiner

Position Summary The Claims Examiner is responsible for processing medical claims in an efficient, cost-effective, and timely manner. Must reside in California or Arizona. Responsible for determining financial responsibility between group, health plans and contracted hospitals for accurate processing of claims. Responsible for preparing, researching, analyzing, pre-coding and the adjudication of all types of claims (Contracted providers, Non-contracted, 1500 or UB claims forms. Recognize the difference between Shared Risk and Full Risk claims. Processes/adjudicates medical claims according to regulatory processing guidelines and in compliance with all federal and state healthcare plan laws and regulations. Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations. Knowledge of Coordination of Benefits. Processing standard of 10 claims or more per hour with a 99% level of accuracy. Prompt and accurate response to claims related questions from Management. Participate in special projects as assigned by Management. Perform other job related duties as assigned. Qualifications High School Diploma or equivalent. Course work and knowledge of medical terminology preferred. At least two years of claims adjudication experience preferred. Knowledge of medical terminology, ICD9 and CPT/HCPCS codes required, including ten-key calculator, computer, and light typing skills 35wpm. Processing experience in a Managed Care/IPA environment preferred. EZ-CAP knowledge preferred. Ability to multi-task in an efficient, thorough, and prioritized manner; to work quickly, accurately, and independently; and, to anticipate needs and solve problems. #J-18808-Ljbffr