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Claims Examiner
Ref No.: 17-01930
Category: Permanent Placement
Location: signal hill, California
Claims Examiner

Essential Duties and Responsibilities:
  • Responsible for accurate and timely adjudication of professional claims according to guidelines and regulatory requirements.
  • Professional claims may include claims from Primary Care Physicians (PCP) and specialists.
  • Adjudicates medical claims according to regulatory requirements and Accountable Health processing guidelines and contractual agreements:
  • Verifies patient account, eligibility, benefits and authorizations.
  • Prioritizes assigned claims according to regulatory timelines.
  • Requests additional information for incomplete or unclean claims; follows up with provider as necessary
  • Meets and/or exceed established productivity and quality standards
  • Immediately notifies Claims Management of potential delays in completing assigned tasks and/or special projects and/or issues affecting timely and accurate completion of assigned tasks
  • Promotes teamwork and cooperation with other staff members and Management
  • Performs other related duties as assigned
  • Communicates with other departments to resolve provider claims related issues.
  • Complies with company's policies and procedures which include but not limited to attendance and punctuality standards and employee conduct.
  • Attends mandatory departmental meetings
  • Understands and abides to the company compliance programs and attend all related mandatory trainings and meetings
  • Ensure the privacy and security of Protected Health Information (PHI) and Protected Identifiable Information (PII) related to HIPAA compliance as outlined in policies and/or federal and state regulations

  • High school diploma or equivalent required; some college preferred
  • 1-2 years medical claims examining experience or completion of a technical class specializing in claims processing
  • Minimum typing speed of 45 WPM and use of Ten-Key by touch
  • Working knowledge of ICD9/ICM10-CM, HCPCS level II and level III or local/state codes, and CPT codes
  • Knowledge of different payment methodologies such as Medi-Cal and Medicare fee schedules
  • Ability to interpret division of financial responsibility (DOFR) and provider contracts
  • Working experience on EZ-CAP, Virtual Examiners and other claims editing software a plus
  • Ability to effectively communicate with internal and external associates
  • Knowledge of regulatory requirements such as Title 28 section 1300.71 Claims Settlement Practices, CMS Part C Claims and Medi-Cal claims and billing guidelines
  • Ability to work in a fast pace environment with minimal supervision
  • Ability to handle multiple projects and is able to prioritize workflow