- Full Time/Contract
- Pasadena, CA
Medical Claims Examiner, Managed Care
The Medical Claims Examiner/processor is responsible for adjudicating medical claims from providers billing Medicare and Medicaid. Duties & responsibilities include but not limited to; the accurate and timely adjudication of paper and/or electronically formatted claims received in the CMS 1500 and/or UB-92 format. This person processes all claims and applicable claims correspondence in accordance with Medicare and Medi-Cal regulatory guidelines, contract provisions and established policies and procedures. Additionally, he/she is responsible for consistently meeting accuracy and productivity targets outlined in the department's performance standard. Quality Assurance and Productivity Standards and HIPAA rules must always be adhered to.
- Review pricing methodology for multiple plans
- Ensures compliance with all applicable Federal, State and/or County laws and regulations related to our documented guidelines and processes
- Maintains compliance with all company policies and procedures
- Processes claims by entering patient, payment and provider information timely and accurately from a UB or CMS claim form
- Identify and correct any and all duplicate or corrected claims received
- Adjudicate claims with a high level of productivity (average 150 claims per day) and minimum average accuracy levels (Procedural accuracy of 97.0% and Financial accuracy of 97.0%) in accordance with all departmental standards
- Claims payment
- Analyzing medical insurance claims for possible claim errors
- Complete other tasks, as assigned
- Answer and respond to internal and external emails in a professional and courteous manner.
- Ensure the privacy and security of PHI (Protected Health Information) as outlined in Company's policies and procedures relating to HIPAA compliance
- High School Diploma or equivalent required
- Minimum of 2-year's medical claims payment experience in an HMO environment (i.e. MSO, IPA or health plan)
- Strong knowledge of Medicare and Medi-Cal managed care claims processing and compliance guidelines.
- Experience with CPT-4, ICD-9CM, ICD-10CM, RBRVS, ASA and HCPCS as well as in depth understanding of Medicare and Medi-Cal guidelines that apply to COB and Medicare Secondary Payer.
- Working knowledge of reimbursement methodologies of professional claims including injectable drugs. Must be detail-oriented, attentive, organized, and able to follow directions.
- Ability to work independently utilizing company established processes.
- Ability to meet deadlines and maintain department quality standards.
- Ability to interact well with providers calling regarding claim status.
- Ability to interact well with fellow employees and supervisors and be ateam player.
- Strong work ethics and professionalism.
- Ability to quickly adapt and gain a sound understanding of claims system
- Intermediate computer skills including Microsoft Word, Excel and Internet navigation.