Senior Claims Examiner

Role Description

At WelbeHealth, we are transforming the reality of senior care by providing an all-inclusive healthcare option to the most vulnerable senior population, while serving as a care provider and care plan to those individuals we serve. Our Health Plan Services team helps ensure excellent care delivery for our participants, and the Senior Claims Examiner plays a pivotal role in ensuring timely and efficient processing of claims for our contracted specialty provider partners.

• Examine claim records and forms to investigate and resolve first level disputes, including completion of acknowledgement and determination letters.
• Review and process second level claims, such as adjustments and corrected claims.
• Work closely with leadership on identified trends related to improper processing and claim-related concerns or discrepancies that result in a dispute.
• Assist the team in carrying out departmental responsibilities and collaborate with others to support short- and long-term goals and priorities.
• Establish and maintain effective working relationships with team and collaboration with interdepartmental staff and leadership.

Qualifications

• Minimum of three (3) years’ health plan claims processing experience, and two (2) years’ health plan claims dispute experience analyzing and resolving provider claims problems.
• Experience in a Managed Care Plan (MCP) or PACE organization (PO) claims processing environment highly preferred.
• In depth experience with Medicare and Medicaid claims processing.
• Strong computer and appropriate software knowledge (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word, Teams) and job specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position.
• Ability to balance competing priorities, exercise discretion, and consider all relevant factors in navigating gray areas and resolving ambiguities.
• Proficient in the principles and practices of managed health care, health care systems and medical terminology (e.g., revenue Codes, Current procedural Terminology (CPT), Healthcare Common Procedure Coding system (HCPCS) and Internal Classification of Disease (ICD-10).
• Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee schedule and Diagnosis Related Groups (DRG) and benefit interpretation and administration.

Benefits

• Apply your claims expertise in meaningful ways as we rapidly expand.
• Medical insurance coverage (Medical, Dental, Vision).
• Work/life balance – we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, and 6 sick days.
• Advancement opportunities - We’ve got a track record of hiring and promoting from within, meaning you can create your own path!
• Compensation consists of base salary plus bonus. WelbeHealth offers a competitive total rewards package that includes a 401(k) match, comprehensive healthcare coverage, and a broad range of additional benefits.
• Compensation Offering: $61,663.43 — $81,395.73 USD.

COVID-19 Vaccination Policy

At WelbeHealth, our mission is to unlock the full potential of our vulnerable seniors. In this spirit, please note that we have a vaccination policy for all our employees and proof of vaccination, or a vaccine declination form will be required prior to employment. WelbeHealth maintains required infection control and PPE standards and has requirements relevant to all team members regarding vaccinations.

Our Commitment to Diversity, Equity and Inclusion

At WelbeHealth, we embrace and cherish the diversity of our team members, and we're committed to building a culture of inclusion and belonging. We're proud to be an equal opportunity employer.

Beware of Scams

Please ensure your application is being submitted through a WelbeHealth sponsored site only. Our emails will come from @welbehealth.com email addresses. You will never be asked to purchase your own employment equipment. You can report suspected scam activity to View email address on remotive.com.