Job description

A Claims Examiner is responsible for analyzing and the adjudication of medical claims as it relates to managed care. Performs payment reconciliations and/or adjustments related to retroactive contract rate and fee schedule changes. Resolve claims payment issues as presented through Provider Dispute Resolution
(PDR) process or from claims incident/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payments. Generates and develop reports which include but not limited to root causes of PDRs and Incidents. Collaborates with other departments and/or providers in successful resolution of claims related issues.

Responsibilities:
1. Process medial claims, professional and institutional as it relates to the appropriate Federal and State regulations based on the member’s Line of Business; Medicare, Medi-Cal, Commercial, PACE Lines of Business.
2. Read and interpret DOFRs as it relates to the claim in order to ensure that group is financially at risk for payment.
3. Read and interpret provider contracts to ensure payment/denial accuracy.
4. Read and interpret Medi-Cal and Medicare Fee Schedules.
5. Correct claims payment/denial errors identified by the Claims Auditor prior to a check run.
6. Must maintain an error accuracy of under 3%.
7. Communicate with Claims Management for any issues relating to provider, fee schedule, eligibility, authorization, or system issues.
8. Assist in the creation of any business rules and training in order for the Claims Department to become more efficient and accurate.
9. Coordinate with the Recovery Department for any identified overpayments.
10. Attend monthly departmental meetings and provide feedback when requested.
11. Other duties as assigned.

Skills and Abilities:
1. Intermediate to advanced word processing, spreadsheet, presentation, and internet skills.
2. Working knowledge of simple and moderate billing and documentation regulations, with the ability to research additional topics when necessary.
3. Knowledge of the reading of a CMS-1500 and UB-04 form.
4. Read, interpret and summarize medical contracts/division responsibility before allowance of payments.
5. Fundamental understanding of managed care as it relates to Medi-Cal, Medicare, and Commercial Lines of Business.
6. Fundamental understanding of Health Plan, State, and Federal regulations.
7. Able to read and interpret Fee schedules, specifically Medi-Cal and Medicare.
8. Strong analytical, detail-oriented skills with the ability to understand healthcare operational processes and technology concepts.
9. Ability to maintain the highest standards of confidentiality and to work with a high degree of integrity to perform objective and constructive audits.
10. Highly motivated with great organizational skills and the ability to multitask, handling interruptions and achieving deadlines.
11. Ability to perform services in a variety of work settings while maintaining a high degree of customer service.
12. Demonstrates a results-oriented approach for delivering service in an accurate, complete, and timely fashion.
13. Demonstrate success working both individually and with a team in a fast-paced, high volume, deadline oriented environment with emphasis on accuracy and timeliness.
14. Excellent communication skills, both oral and written, in order to deal effectively with a variety of interpersonal relationships and situations.
15. Ability to follow up on pending issues and meet deadlines.
16. Ability to cultivate strong working relationships with personnel from various areas of responsibility within the organization and interact with employees, customers and vendors in a professional manner.
17. Must be able to follow directions and perform independently according to departmental standards when no directions are given.
18. Must be able to willingly accept responsibility and possess the desire to learn new tasks.
19. Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.

Education and Experience:
1. HS Diploma or GED
2. Must be knowledgeable of Medi-cal regulations.
3. Preferred knowledge of Medicare and Commercial rules and regulations.
4. Knowledge of medical terminology.
5. Must have an understanding to read and interpret DOFRs and Contracts.
6. Must have an understanding how to read a CMS-1500 and UB-04 form.
7. Must have strong organizational and mathematical skills.

Physical Requirements:
1. Ability to sit, stand, stoop, reach, lift (up to 10 pounds), bend, etc., hand and wrist dexterity to utilize computer.
2. Work is sedentary, involving sitting at a PC and typing. Hand and wrist dexterity to utilize computer and mouse.
3. May require travel to sites/program and special functions.

Environmental Conditions Critical to Performance:
1. Work is in an office environment, climate controlled through central air conditioning.
2. Required to do some traveling by car to various AltaMed sites and events.

Job Type: Full-time

Pay: $24.00 - $29.00 per hour

Benefits:

• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Ability to commute/relocate:

• Montebello, CA 90640: Reliably commute or planning to relocate before starting work (Required)

Work Location: Hybrid remote in Montebello, CA 90640

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