Claims Examiner Iii - Long Beach, United States - Advanced Medical Management, Inc.

Advanced Medical Management, Inc.

Verified Company

Long Beach, United States

2 weeks ago

Posted by:

Mark Lane

beBee recruiter

Claims Examiner III

Role Insights

Primary Responsibilities

Audit claims processing quality, develops, maintains and runs standard reports
Assist the Claims Supervisor/Director in reviewing the quality auditing tracking/reporting (financial and procedural)
Coordinating with various departments to resolve disputes or issues
Maintain the Claims department workflow
Review and process hospital claims and complicated claims to assist claims examiners I, and II
Claims processing to ensure quality (in/out patient hospital claims, Medi-Cal, Commercial, and Medicare claims)
Review auto adjudication of claims
Review carveouts in the Division of Financial Responsibility (DOFR)
Review and process reports and work with management and claims unit
Assist the Claims Manager in reviewing the quality auditing tracking/reporting
Assist with training/supporting the claims team
Recommend and assist in the development of process improvements
Coordinating with various departments to resolve disputes or issues
Able to process a claim and assist the team by answering questions and providing support
Prepare for check runs
Other duties may be assigned as needed to assist the AMM team

Required Skills and Abilities

High School Diploma or GED, some college preferred
35 yrs of claims examiner experience processing professional and facility claims
Strong analytical skills and problem solving skills are necessary
Know the industry guidelines for all LOBs
Proficient with medical terminology, CPT, Revenue codes, ICD10,
Medicare and Medi-Cal claims adjudication experience required
Knowledge of claims processing rules, managed care benefits and adjudication
Strong analytical skills and problemsolving skills are necessary
Familiarity with Medicare guidelines and ICE compliance guidelines
Experience with the handling of claims in a managed care business (HMO)
Extensive knowledge of claims processing and claims data analysis
Experience with EZ-Cap and Encoder Pro preferred
Must be familiar with Microsoft Office (Word, Excel, Outlook)
Must possess a positive attitude, have excellent communication skills and is able to meet deadlines in a fastpaced environment
Must work well under pressure and deadlines