Description
- Adjusts and
adjudicates multiple lines of business in a timely manner to ensure
compliance to departmental and regulatory turn-around time and quality
standards.
- Review
claims and makes payment/adjustment determination to ensure all components
i.e. member, provider, authorization, claim, and system are valid and
correct for accurate processing.
- Conducts
research regarding claim completion and appropriateness; identifies errors
and takes necessary actions to resolve claims.
- Manages work
to meet regulatory guidelines.
Essential
Functions:
- Review claims
and makes payment determination.
- Review and
evaluates claims for proper and correct information including correct
member, provider, authorization, and billing information on which to base
payment determination.
- Refers to
eligibility, authorization, benefit, and pricing information to determine
appropriate course of action (i.e. claim reject/denial, request for
additional information, etc.).
- Conduct
research regarding coordination of benefit issues, fraud and abuse, and
third-party liability.
- Utilizes knowledge
of government regulatory policies and procedures to ensure compliance with
government regulations including but not limited to CMS, DHMC, DOC, DHS,
and requirements of accrediting agencies such as NCQA.
- Prepares
material for audits and provides assistance to Lead and Supervisor during
audit.
- Assist with
the preparation of materials for audits and provides assistance to Lead
and Supervisor during audit.
- Work
together with Lead and Supervisor for claim reporting requirement.
- Review
member/provider claims by checking provider service contracts and other
supporting claims documentation in accordance with service agreements.
- Coordinates
payment agreement with providers.
- Proactively
works to ensure claim review is resolved appropriately.
- Experience
with medical claim audits
Qualifications
Basic Qualifications: Experience
- One (1) year
medical claim adjudication experience.
- Experience
in processing multiple types of medical claims and lines of business
required.
- Problem
solving skills; the ability to systematically analyze problems, draw
relevant conclusions and devise appropriate courses of action.
- Excellent
verbal and written communication skills; ability to speak clearly and
concisely, conveying complex or technical information in a manner that
others can understand, as well as ability to understand and interpret
complex information from others.
- Intermediate
computer skills - Proficiency with Microsoft Word, Outlook and Internet
Explorer, with the ability to navigate a Windows environment.
Additional Requirements:
- Knowledge of
claims processing regulatory guidelines/mandates, i.e. HIPAA, Timelines
Standards, Medical Terminology, etc.
- Knowledge of
various payment methodologies & government reimbursement guidelines.
- Knowledge of
claims categorization/codification guidelines (Revenue Codes, Occurrence
& Condition Codes, CPT/HCPCs codes, and ICD 10 Diagnosis &
Procedure Codes).
- Must have
basic PC skills.
- Related
experience field: Medical Claims Experience
- Working
knowledge of CPT, ICD-10, Medical Terminology, COB/TPL/WC. Excellent
verbal, written and analytical skills.
- Demonstrate
ability to utilize Medical Terminology and International Classification
Diagnosis (ICD-10) coding at a level appropriate to the job.
- Must be able
to work in fast-paced environment.
Preferred
Qualifications:
- Experience
with in-patient claims processing.
- Medical
Terminology Certificate preferred.
Job Type: Full-time
- Monday-
Friday
- 8:30am-5:30pm
- 1 hour lunch
Required
Education:
- High school
or equivalent
Required
experience:
- Medical
Claims Processing: 1 year
Job Type:
Full-time
Benefits:
- Dental
insurance
- Health
insurance
- Paid time
off
- Vision
insurance
Application
Question(s):
- Do you have
medical terminology experience? If so, how long?
Ability to
Commute:
- Buena Park,
CA 90620 (Required)
Work
Location: In person
Resume
submission : info330amm@gmail.com