- Performs through review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services
- Processes non-institutional claim types for all line of business (Medicare, Medical, Commercial, etc)
- The Specialist should clearly understand the products and healthcare benefits services offered to customers, including cost share, limits and regulatory rules and guidelines
- Configure provider contracts, Fee schedule updates and other documents
- Develop configuration testing & validate accuracy of data loaded
- Communicated required system updates to Provider Contracting & Claims operations
- Coordinate research & resolution of debarred & sanctioned providers
- Corrects system generated errors manually prior to final claims adjudication
- Communicated required system updates to Provider Contracting & Claims operations
- Process claims based upon the provider's contract/agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and NMM policies and procedures
- Analyzes and validates Medi-cal pricing researches, Adjusts and adjudicates claims reviews services for accurate charges and utilizes current billing code sets, (i.e International Classification Diseases (ICD 10) Codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference
- Validates eligibility and other possible health insurance coverage on the claims (i.e Medicare primary, California Children services (CCS),,)
- Alerts manager or supervisor of more complex issues that arise
- Processes claim exception reports as assigned
- Recognize claim correspondences from multiple IPAs
- Recognize the health plan financial risk (Division of Financial Responsibility)
- Recognize the difference between Shared Risk and Full Risk claims
- Maintain required levels of production and quality standards as established by management
- Attendance at employer worksite is an essential job requirement
- Work assigned claim project to completion
- Contribute to team effort by accomplishing related results as needed
- Knowledge of MS Word, Excel and basic medical terminology
- High School graduate or equivalent requires
- EZ-CAP knowledge; or equivalent combination of education and experience
- Excellent knowledge of CPT, HCPCS, ICD-10 CM, ICD-10 PCS, etc
- Typing speed 70+ WPM and knowledge of 10 key desired
- Ability to multi-task and meet deadlines
- Strong organization skills; ability to multitask and properly manage time
- Position may require unscheduled overtime, week-end work
- Ability to understand work with proprietary software applications
- Organizational ability and ability to exercise good judgment
- Work independently as part of a team
- At least 2 year plus of claims processing experience in the health insurance industry or medical health care delivery system
- Put Patients First
- Empower Entrepreneurial Provider and Care Teams
- Operate with Integrity and Excellence
- Be Innovative
- Work as One Team
- Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr, Monterey Park, CA
- The total compensation target pay range for this role is $ $30.00 per hour. The salary range represents our national target range for this role.
-
Claims Examiner Iii
1 day ago
Advanced Medical Management, Inc. Long Beach, United States**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) ...
-
Claims Examiner Iii
5 days ago
TRISTAR RISK MANAGEMENT Signal Hill, United States**This position requires the employee to be bilingual English/ Spanish.** · ***:Under mínimal supervision manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines. · This position requires considerable interaction w ...
-
Claims Examiner III
6 days ago
Imperial Health Plan of California, Inc. Pasadena, United StatesJOB SUMMARY: Is responsible for adjudicating complex claims which include high dollar claims. Responsible for accurate manual/auto pricing of claims. Identify provider billing issues that impact claims processing. Works closely with the Supervisor to identify any reporting or tra ...
-
Claims Examiner III
2 days ago
Tristar Insurance Services LLC Signal Hill, United StatesJob Details · Level · Experienced · Job Location · Signal Hill Office - Signal Hill, CA · Remote Type · Fully Remote · Position Type · Full Time · Education Level · High School Diploma or GED · Salary Range · $85, $95,000.00 Salary/year · Travel Percentage · None · ...
-
Claims Examiner II/III
1 week ago
Innovative Management Systems Incorporated Bassett, United States:We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and ...
-
Claims Examiner II/III
1 week ago
Innovative Management Systems Incorporated Bassett, United States:We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and ...
-
Claims Examiner II/III
1 week ago
Innovative Management Systems Incorporated CITY OF INDUSTRY, CA, US, United States Full time:We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and ...
-
Claims Examiner II/III
6 days ago
Innovative Management Systems, Inc. La Puente, United StatesJob Type · Full-time · Description · We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, ...
-
Claims Examiner II/III
2 weeks ago
Innovative Management Systems Incorporated La Puente, United States: We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, an ...
-
Medical Claims Examiner III
1 week ago
Ultimate Staffing Long Beach, United StatesJob 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 reporti ...
-
Procom Long Beach, United States(Workers Compensation Claims Examiner Level III) Intro · Our client, the largest privately held third party claims administrator in the United States, is seeking a Workers Compensation Claims Examiner Level III. The ideal candidate will have a minimum of 5 years of experience in ...
-
Unarmed Guard
6 days ago
Savage III, Inc. Los Angeles, United States**Security Guard (Unarmed) - Greater Los Angeles Area** · **Savage III, Inc. - Greater Los Angeles Area** · **UNARMED SECURITY GUARD** · **Savage III, Inc. - Executive Protective Agency - Los Angeles & Surrounding Area** · **Who We Are** - Savage III, Inc. is an elite executive p ...
-
Supply Officer I
5 days ago
Los Angeles County Department of Human Resources Los Angeles County, CA, United States**EXAM NUMBER**: · - PH2373B**TYPE OF RECRUITMENT**: · OPEN COMPETITIVE JOB OPPORTUNITY · **FILING DATE**: · Tuesday, May 14, 2024 at 8:30 a.m._,_ Pacific Time (PT)**DEFINITION**: · - Has comprehensive responsibility for supply and related functions in a large department. · - **C ...
-
Office Technician
3 days ago
Department of Industrial Relations Los Angeles County, CA, United StatesUnder direction of the Deputy Labor Commissioner III, in the State Labor Commissioner's Office of the Bureau of Field Enforcement (BOFE) Program, The Office Technician (Typing) will greet visitors, answer general questions, and/or direct them to the appropriate individual(s); eff ...
-
Deputy Labor Commissioner Ii
6 days ago
Department of Industrial Relations Los Angeles County, CA, United StatesUnder the direction of the Deputy Labor Commissioner III (Senior Deputy) in the Wage Claims Adjudication (WCA) program, the Deputy Labor Commissioner II (DLC II) proactively investigates and adjudicates claims to verify and determine compliance to the extent permitted by law. The ...
-
Program Representative Iii
1 day ago
Department of Consumer Affairs Los Angeles County, CA, United StatesUnder the general direction of the Program Manager I, the Program Representative III (Supervisor) supervises a Forensic Documentation Lab that provides BAR Enforcement staff with documented state undercover vehicles and forensic vehicle repair analysis services. · Please refer to ...
-
Clinic Driver
5 days ago
Los Angeles County Department of Human Resources Los Angeles County, CA, United States**EXAM NUMBER**: · PH5064B · **FILING PERIOD**: · **Tuesday, April 16, 2024 **at 8:30 a.m., Pacific Time (PT)** · **THIS ANNOUNCEMENT IS A REPOSTING TO REOPEN THE FILING PERIOD AND UPDATE BULLETIN INFORMATION.** · **_ · **TYPE OF RECRUITMENT**: · Open Competitive Job Opportunity ...
-
Psychiatric Technician
5 days ago
California Correctional Health Care Services Los Angeles County, CA, United States**California State Prison, Los Angeles County (LAC) is located in Lancaster, CA, which is 45 miles north of Los Angeles, CA.** · Under the supervision of the Supervising Registered Nurse II/III, Correctional Facility, Unit Supervisor (Safety), or Senior Psychiatric Technician (Sa ...
-
Staff Analyst, Commission Services
5 days ago
Los Angeles County Department of Human Resources Los Angeles County, CA, United States**EXECUTIVE OFFICE OF THE BOARD OF SUPERVISORS** · **FIRST DAY OF FILING** · - Applications will be accepted starting **May 14,** 2024 at 8:00 a.m. (PT)** and will remain open until the needs of the Department are met. Filing may close at any time without prior notice. · **EXAM N ...
-
Chiropractor - West Covina, Ca
1 week ago
The Joint Chiropractic West Covina, United States**Looking for a new way of delivering quality chiropractic care?** · **The right adjustment is all it takes.** · Here at The Joint Chiropractic, we've got your back. As one of our doctors, you will find that our unique operating model gives you all the support you need to focus o ...
Claims Examiner III - Monterey Park, United States - Astrana Health
Description
Job Title: Claims Examiner III
Department: Operations - Claims
About the Role:
We are currently seeking a highly motivated Claims Examiner. This role will report to the Manager - Claims and enable us to continue to scale in the healthcare industry.
What You'll Do:
Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise in order to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.
Our platform currently empowers over 10,000 physicians to provide care for over 1.2 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise in order to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.
Our Values:
Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
