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Santa Fe Springs

    Claims Examiner - Santa Fe Springs, United States - Managed Staffing

    Managed Staffing
    Managed Staffing Santa Fe Springs, United States

    2 weeks ago

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    Description

    Job Description

    Job Description

    Job Title: Claims Examiner

    Location: 9557 Greenleaf Avenue, Whittier, CA

    Shift: Monday - Friday, 07:00 am - 03:30 pm

    Experience Requirement: Minimum of 2 years of adjudication-related experience in an ambulatory, acute care hospital, HMO, or IPA environment.

    Position Summary: The Claims Examiner directly reports to the Claims Manager and is primarily responsible for processing UB-92 and HCFA-1500 claims received from PHP affiliated medical groups and hospitals for HMO patients. This role involves operation, adjudication, and payment of claims.

    Education/Experience/Training:

    • High school graduate or equivalent required. Must provide physical proof if background check cannot verify education background.
    • Minimum of 2 years of 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.
    • Understanding of timeliness and payment accuracy guidelines for commercial, senior, and Medi-Cal claims.
    • Familiarity with compliance issues related to claims processing.
    • Experience in interpreting provider contract reimbursement terms is desirable.
    • Ability to identify non-contracted providers for Letter of Agreement consideration.
    • Data entry experience.

    Education Requirement:

    • Must be able to verify high school diploma or GED or higher education. Candidates should provide complete dates, and if there have been issues verifying their education, documents should be available for verification.
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