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Claims Examiner

Company: MemorialCare Health System
Location: Tustin
Posted on: October 26, 2019

Job Description:

Job Details Company Overview Description PurposeStatement / Position Summary The Claims Examiner I accurately review, researches and analyzesprofessional claims. Makes benefitdeterminations and calculations of type and level of benefit based onestablished criteria and provider contracts. Essential Functions and Responsibilities of the Job - Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines. - Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims. - Process HCFA 1500s and COB claims. - Reviews, processes and adjudicate claims for payment accuracy or denial of payment according to Department's policy and procedures. - Processes all claims accurately conforming to quality and production standards and specifications in a timely manner. - Documents resolution of claims to support claim payment and/or decisions appropriately. - Makes benefit determinations and calculations of type and level of benefits based on established criteria and provider contracts. - Understands and interprets health plan Division of Financial Responsibilities and contract verbiage. - Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines. - Adjudication of Commercial and Medicare Advantage claims. - Ability to prioritize, multitask and manage claims assignment within department goals and regulatory compliance and with minimal supervision. - Ability to make phone calls to Provider/Billing offices when necessary based on department guidelines. - Requests additional information or follow up with provider for incomplete or unclean claims. - Ability to effectively communicate with External and Internal teams to resolve claims issues. - Ability to interact in a positive and constructive manner. Essential Job Outcomes - Process 125 claims daily/8 hour shift. - Consistently meet 98% processing accuracy in paid and denied claims. - Ability to be at work and be on time. - Perform other duties as assigned by Management. Qualifications Experience - Ten key by touch. - Type a minimum of 45 words per minute. - Basic claims processing knowledge. - Able to recognize CMS 1500 and UB 04 forms. - Basic knowledge of CPT, ICD-9 codes and ICD-10 codes. - Understands division of financial responsibility for determination of financial risk. - Demonstrate effective communication, interpersonal, and organizational skills. - Excellent written & oral communication skills. - Ability to follow instructions. Education - High School Diploma Job: United States-California-Tustin Primary Location: Schedule: Full-time Shift: Regular Job Posting: Recommended skills Medicare Advantage Claims Coordinating Self Motivation Cpt Coding Implantable Cardioverter Defibrillator

Keywords: MemorialCare Health System, Tustin , Claims Examiner, Other , Tustin, California

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