- Full Time/Contract
- Tustin, CA
Our client is a is a nonprofit integrated delivery system that includes multiple top hospitals, health plans and freestanding ambulatory surgery centers in Orange and Los Angeles Counties. An innovator in healthcare delivery, our client focuses on evidence-based, best practice medicine and has gained widespread recognition for their approach in healthcare.
The Claims Examiner I accurately reviews, researches and analyzes professional claims. Makes benefit determinations and calculations of type and level of benefit based on established criteria and provider contracts.
Essential Functions and Responsibilities
- Identifies authorizations and matches authorization to claims.
- Adjudicate claims in the correct financial bank. Identifies dual coverage and potential third-party liability claims. Refers claims with Coordination of Benefits to Management to approve and update system insurance coverage profile.
- Determines out-of-network and out-of-area services or providers and processes in accordance with company and governmental guidelines.
- Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.
- Processes all claims, eligible or ineligible accurately conforming to quality and production standards and specifications in a timely manner.
- Supports other Examiners in adjudicating claims from other Health Plans.
- Adjudication of Commercial and Medicare Advantage claims.
- Documents resolution of claims to support claim payment and/or decisions.
QUALIFICATIONS / REQUIREMENTS
- Ten key by touch.
- Type a minimum of 45 words per minute.
- Basic claims processing knowledge.
- Able to recognize HCFA 1500 forms.
- Basic knowledge of CPT and ICD-9 codes.
- Understands division of financial responsibility for determination of financial risk.
- Demonstrate effective communication, interpersonal, and organizational skills.
- Excellent written & oral communication skills.
- Ability to follow instructions.
- High School Diploma
$16.50/hr – $20.00/hr