Senior Claims Examiner - Full Time

Responsibilities Come and join the RMC Family! We have been in the community since 1935. Our mission is to provide comprehensive multi-specialty medical services in the greater Riverside region. Your passion, inspiration, and talents are invaluable to us and our mission to serve others. Our facility can provide a place for you to thrive and continue your professional development. Quality Healthcare is our passion, improving lives is our reward. We are working to change lives and transform the delivery of healthcare. Riverside Medical Clinic is the best place to work, practice medicine, and receive care. Summary: Responsible for preparing, researching, analyzing, pre-coding and the adjudication of all types of claims (Contracted providers, Non-contracted, 1500 or UB claims forms, Senior and Commercial plans) received at RMC from outside providers for processing. Managed Care claims are processed in accordance with the outside Provider Contract, State, Federal, CMS, DMHC and Health Plan guidelines and regulations. Must maintain a processing standard of 10 claims per hour with a 90% level of accuracy, both clerical and financial. Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Must have knowledge and understanding of claims processing. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education and/or Experience: High school diploma or general education degree (GED); or three or more year's related experience and/or training; or equivalent combination of education and or experience. Certificates, Licenses and Registrations: None. Essential Functions: Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job's purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable. Note: (other duties may be assigned, deleted or changed at any time, at the discretion of management, formally, or informally, either verbally or in writing).

1. Sort claims for adjudication according to type. If the claim is from a contracted provider, research the provider's contract and verify the rate information.
2. Non-contracted provider claims, with or without prior authorization, are to be submitted to the Contracts Coordinator for a Letter of Agreement, on a Green "LOA Request Form", prior to processing.
3. Pre-code claims, with the provider identification number, rates to be paid, EOB code, authorization and co-pay (if applicable) prior to entering the claims in the Managed Care system.
4. Re-verify that the patient account, family member number, date of birth, and HMO insurance information is correct, prior to entering the claim.
5. Claims are entered in to the computer system and to be adjudicated according to all State, Federal regulations, CPT, DX, Correct Coding, health plan, provider contracts and departmental policies and guidelines, either for pend, payment or denial.
6. If the service the provider is billing was not prior authorized, and the claim is NOT an Emergency Department visit, and the claim was not billed with pertinent medical information in order to make a payment determination, request the additional information, from providers outlining the specific information required. Status the claim using EOB code "P3" and follow up as required.
7. If a claim was billed with invalid CPT or Diagnosis codes, deny claims as "incomplete/unclean", and note the specific reason in the claim notes.
8. When a Case Manager in the Utilization Management department reviewed a claim retrospectively, and a determination was made to deny the claim to the member; process the denied claim in the system, using EOB code 3.UM. Review claim to ensure appropriate denial letters have been attached prior to closing the batch.
9. Enter all member denials in to the computer system immediately upon receipt to ensure closure no later than the following week check run.
10. Ensure that all claims that have been identified as ERISA, and a determination has been made to deny to the member, adjudicate and close the claim within 30 calendar days from receipt.
11. Once the claims have been adjudicated in the system, match complete claims with the batch edit and review the processed claims for accuracy, prior to closure.
12. Once the edit has been reviewed ensure all matching documentation is attached, and forward to the Claims Auditors for review.
13. Notify management when claims cannot be processed within regulatory guidelines for timely claim processing.
14. Maintain productivity and accuracy standards of 10 claims per hour with a 90% level of financial and clerical accuracy.

This opportunity offers the following Challenging and rewarding work environment Growth and Development Opportunities within UHS and its Subsidiaries Competitive Compensation About Universal Health Services One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World's Most Admired Companies by Fortune; and listed in Forbes ranking of America's Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. #J-18808-Ljbffr Universal Health Services