Claims Examiner III

Department: Ops - Claims Ops

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Sarah Chan

Compensation: $28.00 - $32.00 / hour

Description

What You'll Do

• Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-10 codes, under the correct provider and member benefits
• Review and process facility (UB-04) and professional claims (CMS-1500) 
• Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups’ and company policies and procedures
• Process Medicare member claims based on DMHC and DHS regulatory legislature
• Respond to and resolve provider and health plan claims inquiries and give resolution in a timely manner
• Review services for appropriateness of charges and apply authorization guidelines during claims processing
• Monitor and track age, pended, and open reports to maintain timeliness in claims processing based on individual work allocation reports
• Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines
• Participate in special projects, complete tasks assigned by management and attend meetings/conference calls as necessary
• Loading and entering claims 
• Other duties as assigned

Qualifications

• Must have at least 3 years of applicable healthcare claims adjudication experience within the managed care industry for a level I or II and at least 4 years for Senior level claims
• Candidates with multi-product line claims adjustment experience, preferred
• Must be familiar with ICD-10, HCPCS, CPT coding, APC, ASC and DRG pricing, CMS, DMHC regulations, facility and professional claim billing practices
• Must possess proficient filing, general clerical, verbal and written communication and 
  presentations skills
• Must be able to problem-solve, follow guidelines, multi-task, and work comfortably within a team-oriented environment
• Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and Ez-cap Claims adjudication software, preferred
• Ability to type with accuracy and speed of at least 35 wpm
• Associate's degree (A. A.) or equivalent from two-year college or technical school; some college courses, or six months to one year related experience and/or training; or equivalent combination of education and experience

Environmental Job Requirements and Working Conditions

• Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr., Monterey Park, CA 91754.
• The national target pay range for this role is: $28.00 - $32.00 per hour. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.