Medical Claims Examiner III - Long Beach, United States - Ultimate Staffing

Description

Job Responsibilities:

• Manage and ensure compliance with provider contract obligations.
• Conduct quality audits of claims processing, including generating and maintaining standard reports.
• Collaborate with the Claims Supervisor/Director to assess auditing tracking and reporting.
• Coordinate with various departments to resolve disputes and address issues.
• Maintain the workflow within the Claims department.
• Review and process complex hospital claims to support claims examiners I and II.
• Ensure quality processing of various types of claims (e.g., in/outpatient hospital claims, Medi-cal, Commercial, and Medi-care claims).
• Assess auto adjudication outcomes and review carve-outs in the Division of Financial Responsibility (DOFR).
• Process reports and collaborate with management and claims unit as necessary.
• Support Claims Manager in reviewing auditing tracking and reporting.
• Provide training and support to the claims team.
• Identify and suggest process improvements.
• Handle claim processing and provide team support by addressing inquiries.
• Prepare for check runs and perform other duties as assigned by the AMM team.

Required Skills and Abilities:

• High School Diploma or GED, with some college coursework preferred.
• 3-5 years of experience as a claims examiner handling professional and facility claims.
• Strong analytical and problem-solving skills.
• Familiarity with industry guidelines across all lines of business (LOBs).
• Proficiency in medical terminology, CPT, Revenue codes, and ICD-10.
• Experience in Medicare and Medi-Cal claims adjudication.
• Understanding of claims processing rules, managed care benefits, and adjudication.
• Knowledge of Medicare guidelines and ICE compliance.
• Experience in managed care business (HMO) is preferred.
• Extensive knowledge of claims processing and data analysis.
• Familiarity with EZ-Cap and Encoder Pro is advantageous.
• Proficiency in Microsoft Office applications (Word, Excel, Outlook).
  

All qualified applicants will receive consideration for employment without regard torace, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status.We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance.