Claims Processor - La Habra, United States - Ultimate Staffing

Description

The Claims Processor is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes:

1) Processing claims for all lines of business, including complex claims
2) Monitoring itemized billings for excessive charges, duplications, unbundling, and medical coding
3) Determining prior authorization/precertification of services paid via system and/or health services
4) Requesting and reviewing medical records as needed for basic information to validate billing information
5) Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated.
6) Meeting and exceeding performance measurements for Claim Examiners as required by department to meet regulatory compliance.

Processing incoming claims:
1) Determining correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions.
2) Processing all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner.
3) Documenting provider claims/billing forms to support payments/decisions.
4) Identifies dual coverage and potential third-party savings/recovery.
5) Maintaining department databases used for report production and tracking on-going work.
6) Claims will be processed within the contractual and/or regulatory time frames.

• Perform special projects and ad-hoc reporting as necessary. Projects will be complete, and reports will be generated within the specific time frame agreed upon at the time of assignment.
• Working with internal departments to resolve issues preventing claims processing or enhancing processing capabilities.
• May assist in testing, changing, analyzing and reporting of specific enhancements.
• Any other duties as assigned by management.

Minimum Qualifications:

• High School diploma or GED Required.
• 4+ years processing claims/invoices experience preferred.
• Demonstrated experience in providing exceptional customer support in a fast-paced environment.
• Must pass a Criminal Background Screening.
• Must pass government exclusion list at time of hire and monthly thereafter.
• Familiarity with various basic PC usage.
• Able to type at least 40 wpm.
• Availability to work any day and any shift; holidays and weekends

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.