TEMP - Claims Examiner Lead

Company: Impresiv Health
Location: Orange
Posted on: August 2, 2022

Job Description:

TEMP - Claims Examiner Lead
Job Summary

This position is responsible for analyzing and validating claims elements and claims processing. The senior level examiner is responsible for adjudicating more complex claims, requiring additional research or problem-solving.

Position Responsibilities

Processes both professional and institutional claim types.

Performs thorough review of pending claims for billing errors and questionable billing practices that might include duplicate billing and unbundling of services.

Responsible for manually correcting system-generated errors prior to final claims adjudication.

Analyzes and validates Medi-Cal pricing; researches, adjusts, and adjudicates claims; reviews services for accurate charges, utilizing billing code sets and/or authorization guidelines as a reference.

Alerts manager or supervisor of more complex issues that arise.

Processes claim exception reports as assigned.

Maintains quality and productivity standards as set by management.

Other projects and duties as assigned.

Possesses the Ability To:

Meet and maintain established quality and production standards.

Work independently and as part of a team.

Establish and maintain effective working relationships with CalOptima leadership and staff.

Communicate clearly and concisely, both verbally and in writing.

Handle multiple tasks and meet deadlines.

Utilize and access computer and appropriate software (e.g., Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.

Experience & Education:

High School diploma or equivalent required.

3 years of experience processing online claims in a managed care environment required.

Preferred Qualifications:

Experience processing Medi-Cal and/or Medicare claims preferred.

Knowledge of:

Revenue codes and billing code sets, i.e., Current Procedural Terminology (CPT), Healthcare Common Procedural Coding System, International Classification Diseases-10 (ICD-10) Codes and medical terminology.

Industry pricing methodologies, such as Resource Based Relative Value Scale, Medi-Cal Fee Schedule, etc.

Benefit interpretation and administration.

Medicare/Medi-Cal guidelines and regulations.

Keywords: Impresiv Health, Orange , TEMP - Claims Examiner Lead, Other , Orange, California