Claims Examiner

We are seeking a detail-oriented and analytical Claims Examiner to join our team. In this role, you will be responsible for reviewing and processing claims in accordance with established guidelines and procedures. You will evaluate and determine the validity of claims, ensure accuracy in documentation, and ensure compliance with company policies and legal regulations. Your attention to detail and strong communication skills will play a vital role in ensuring the timely and accurate resolution of claims.

What You'll Do:

• Analyze and assess incoming claims to ensure they meet company, regulatory, and legal requirements.
• Make decisions regarding the approval, denial, or adjustment of claims based on established guidelines and criteria.
• Ensure all required documentation is complete, accurate, and appropriately submitted for processing.
• Maintain accurate records of claims status, outcomes, and any adjustments made in the system.
• Perform thorough reviews of pended claims for billing errors and/or questionable billing practices, including duplicate billing and unbundling of services.
• Process both Professional and Institutional claims for all lines of business (Medicare, Medical, Commercial, etc.).
• Configure provider contracts, fee schedule updates, and other related documents.
• Correct system-generated errors manually prior to final claims adjudication.
• Process claims based on the provider’s contract/agreements or pricing agreements.
• Validate eligibility and other possible health insurance coverage on the claims (e.g., Medicare primary, California Children's Services (CCS), etc.).
• Alert managers or supervisors of more complex issues that arise.
• Recognize claim correspondences from multiple IPAs.
• Understand 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.
• Contribute to the team effort by accomplishing related results as needed.

Qualifications:

• Strong understanding of claims lines of business (Medicare, Medical, Commercial, etc.).
• Knowledge of MS Word, Excel, and basic medical terminology.
• Any graduate or equivalent.
• Excellent knowledge of CPT, HCPCS, ICD-10 CM, ICD-10 PCS, etc.
• Ability to multi-task and meet deadlines.
• Strong organizational skills; ability to multitask and properly manage time.
• Ability to understand and work with proprietary software applications.
• Ability to work independently as well as part of a team.
• At least 1 year of claims processing experience in the health insurance industry or medical healthcare delivery system.

You're Great for This Role If:

• Have experience with EZ-CAP, Quickcap, or other Payerspace systems.
• Hold a certification in claims processing or adjudication.