TEMP - Claims Examiner Lead
Company: Impresiv Health
Location: Orange
Posted on: August 2, 2022
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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
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