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Whittier

    Claims Examiner - Whittier, United States - E-Solutions

    E-Solutions
    E-Solutions Whittier, United States

    3 weeks ago

    Default job background
    Description

    POSITION SUMMARY:

    The claims examiner reports directly to the claims manager. They are primarily responsible for the processing functions (operation, adjudication, and payment) of UB-92 and HCFA-1500 claims that are received from PHP affiliated medical groups and hospitals for HMO patients.

    EDUCATION/EXPERIENCE/TRAINING:


    • Minimum of 2 years claims ADJUDICATION related experience in ambulatory, acute care hospital, HMO, or IPA environment


    • Knowledge of payment methodologies for: Professional (MD), Hospital, Skilled Nursing Facilities, and Ancillary Services

    Knowledge and understanding of timeliness and payment accuracy guidelines for commercial, senior and Medi-Cal claims

    Knowledge of compliance issues as they relate to claims processing


    • Experience in interpreting provider contract reimbursement terms desirable


    • Ability to identify non-contracted providers for Letter of Agreement consideration


    • Data entry experience


    • Training on basic office automation and managed care computer systems

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