What are the responsibilities and job description for the Claims Examiner - II position at Imperial Health Plan of California?
People are the most important asset of Imperial, for this reason the difference and plurality of people, equality of opportunities, non-discrimination and inclusion in the workplace are priority and strategic factors in the Organization. Imperial maintains a strong will to promote Diversity, Equity, and Inclusion, through inclusive leadership as a lever change and business sustainability.
JOB SUMMARY:
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 training needs and system problems that may be encountered. Maintains quality and production standards, teamwork and comply with company/administrative policies and guidelines
ESSENTIAL JOB FUNCTIONS:
1. Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e. co-payment, deductible, etc.
2. Review and process facility (UB-04) and professional claims (CMS-1500).
3. Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups’ and company policies and procedures.
4. Process Medicare member claims based on DMHC and DHS regulatory legislature.
5. Respond to and resolve provider and health plan claims inquiries and give resolution in a timely manner.
- Review services for appropriateness of charges and apply authorization guidelines during claims processing.
9. Ensures compliance with all applicable Federal, State and/or County laws and regulations related to our documented guidelines and processes.
Responsibilities
- Review and analyze claims to ensure compliance with relevant laws and regulations.
- Negotiate settlements with claimants while maintaining exceptional customer service.
- Utilize financial software to assess and process claims efficiently.
- Detect and prevent fraudulent claims through thorough investigation and analysis.
- Stay updated on workers' compensation laws to provide accurate guidance and support.
- Organize and maintain detailed records of claims and communications.
EDUCATION/EXPERIENCE:
· Associate degree (A. A.) or equivalent from two-year college or technical school; some college courses, or six months to one-year related experience and/or training; or equivalent combination of education and experience
· Must have at least 4 years of applicable healthcare claims adjudication experience within the managed care industry
· Experience with ICD-9, HCPCS, CPT coding, APC, ASC and DRG pricing, CMS, DMHC regulations, facility and professional claim billing practices required
· Multi-product line claims adjustment experience, preferred
Job Type: Full-time
Pay: $22.00 - $24.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Employee discount
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Referral program
- Retirement plan
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
Education:
- High school or equivalent (Preferred)
Work Location: In person
Salary : $22 - $24
