Description

• Adjusts and adjudicates multiple lines of business in a timely manner to ensure compliance to departmental and regulatory turn-around time and quality standards.

• Review claims and makes payment/adjustment determination to ensure all components i.e. member, provider, authorization, claim, and system are valid and correct for accurate processing.

• Conducts research regarding claim completion and appropriateness; identifies errors and takes necessary actions to resolve claims.

• Manages work to meet regulatory guidelines.

Essential Functions:

• Review claims and makes payment determination.

• Review and evaluates claims for proper and correct information including correct member, provider, authorization, and billing information on which to base payment determination.

• Refers to eligibility, authorization, benefit, and pricing information to determine appropriate course of action (i.e. claim reject/denial, request for additional information, etc.).

• Conduct research regarding coordination of benefit issues, fraud and abuse, and third-party liability.

• Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but not limited to CMS, DHMC, DOC, DHS, and requirements of accrediting agencies such as NCQA.

• Prepares material for audits and provides assistance to Lead and Supervisor during audit.

• Assist with the preparation of materials for audits and provides assistance to Lead and Supervisor during audit.

• Work together with Lead and Supervisor for claim reporting requirement.

• Review member/provider claims by checking provider service contracts and other supporting claims documentation in accordance with service agreements.

• Coordinates payment agreement with providers.

• Proactively works to ensure claim review is resolved appropriately.

• Experience with medical claim audits

Qualifications

Basic Qualifications: Experience

• One (1) year medical claim adjudication experience.

• Experience in processing multiple types of medical claims and lines of business required.

• Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.

• Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.

• Intermediate computer skills - Proficiency with Microsoft Word, Outlook and Internet Explorer, with the ability to navigate a Windows environment.

Additional Requirements:

• Knowledge of claims processing regulatory guidelines/mandates, i.e. HIPAA, Timelines Standards, Medical Terminology, etc.

• Knowledge of various payment methodologies & government reimbursement guidelines.

• Knowledge of claims categorization/codification guidelines (Revenue Codes, Occurrence & Condition Codes, CPT/HCPCs codes, and ICD 10 Diagnosis & Procedure Codes).

• Must have basic PC skills.

• Related experience field: Medical Claims Experience

• Working knowledge of CPT, ICD-10, Medical Terminology, COB/TPL/WC. Excellent verbal, written and analytical skills.

• Demonstrate ability to utilize Medical Terminology and International Classification Diagnosis (ICD-10) coding at a level appropriate to the job.

• Must be able to work in fast-paced environment.

Preferred Qualifications:

• Experience with in-patient claims processing.

• Medical Terminology Certificate preferred.

Job Type:

• Full-time

• Monday- Friday

• 8:30am-5:30pm

• 1 hour lunch

Required Education:

• High school or equivalent

Required experience:

• Medical Claims Processing: 1 year

Job Type: Full-time

Benefits:

• Dental insurance

• Health insurance

• Paid time off

• Vision insurance

Application Question(s):

• Do you have medical terminology experience? If so, how long?

Ability to Commute:

• Buena Park, CA 90620 (Required)

Work Location: In person

Resume submission : info330amm@gmail.com