Claims Examiner - Los Angeles, United States - MedPOINT Management

Job Description

Summary:

Accurately handle, process and assess provider specialty claims, such as UB04s, following external regulations, internal standards, and contractual commitments. Understanding of medical terminology is crucial. Profound knowledge of Commercial, Medicare, and Medi-Cal codes. Basic computer skills required for research and review.

Duties and Responsibilities:

• Accurately review all incoming Provider claims to ensure availability of necessary information.
• Achieve production standards for Hospital and IPA claims as set by claims management.
• Support other IPAs when necessary.
• Enter claims data accurately into the computerized adjudication system.
• Keep comprehensive documentation of processed claims and pending claims.
• Adjudicate claims following departmental policies, procedures, and relevant specialty claims regulations.
• Maintain production standards defined by claims management.
• Collaborate on resolving claims issues with other Departments or Payers.
• Assist Providers, Members, and other Departments in claims investigation.
• Serve as backup for other examiners in the Department.
• Contribute to the training of new claims staff.
• Foster a cooperative environment among all personnel.
• Participate in organizational meetings as needed.
• Adhere to organizational policies and procedures.
• Handle Customer Care inquiries.
• Perform additional tasks as assigned by supervisor/manager.

Minimum Job Requirements:

High school diploma or equivalent. One year of experience as a Claims Examiner using an automated adjudication system. Strong organizational and mathematical abilities. Proficiency in generating claims status reports and check runs.

Knowledge, Skills, and Abilities Required:

• Preferred experience in a managed care setting.
• Knowledge of ICD-9, ICD-10, and CPT-4 coding preferred.
• Detail-oriented with the capacity to work independently.