Medical Claims Processor (Mid-Level)

Local 1014, the self-funded ERISA Trust dedicated to serving the well-being of the Los Angels County Fire Fighters and their families, is seeking a full-time medical Senior Claims Adjuster. The ideal candidate will be processing more complex claims and should be extremely confident and will be trusted to make independent decisions. This position is Monday to Friday with frequent potential for overtime and is NOT remote.

Position Overview:

The Senior Claims Adjuster will be handling facility, ancillary, and Blue Card claims based on medical authorization and apply all applicable coding edits, contractual agreements, and Plan provisions, as well as claims requiring greater confidentiality. Provide back-up support to Member Services, fielding incoming telephone calls from members and providers as needed upon request of Claims Manager. While certain companies find ways to deny claims, we find ways to approve them.

Essential Job Functions:

• Process claims in Anthem and Basis systems
• Process paper (manual) and electronic professional, facility, ancillary, and Blue Card (out of state) claim submissions as appropriate (pay, deny, pend).
• Research, resolve and process adjustment claims (active or re-opened) that are more difficult, complex or escalated claims.
• Process out of network claims requiring negotiation by E-Plan vendor.
• Review all claims for potential fraud, waste and abuse, hospital acquired conditions and events.
• Identify claims with Workers’ Compensation or Third Party Liability potential and refer to appropriate area for further investigation.
• Identify claims requiring clinical review, obtain appropriate medical records, and refer to Claims Manager for review.
• Interface with members and providers; periodically follow-up on pended claims; completion of error corrections; and adjustment of claims as necessary.

Required Knowledge/Skills/Abilities/Experience

• Minimum of 4 years in a Claims Processor role
• 4 years desired as a health claims examiner processing Group Medical claims or equivalent education/experience such as healthcare benefits, benefit administration or health care delivery from either a payer or provider perspective.
• Expert knowledge of medical terminology, facility and physician billing practices, and CPT, ICD-9/ICD-10, HCPCS, DRG and Revenue code coding methodologies.
• Expert knowledge of the Plan in terms of covered expenses and exclusions, coordination of benefits and third-party liability provisions.
• Ability to work under pressure and adapt to changing environments.

Amazing Compensation & Benefits Package (all start day 1 of employment)

• $30/hr
• 100% covered benefits for employee AND dependents
• 401k Matching up to 8.3% of base pay
• 13 holidays, 2 weeks vacation, 12 sick days100% covered benefits for employees and dependents
• Mon - Fri 8:30 - 4:30 (no holidays or weekends)

Pay: $30.00 per hour

Benefits:

• Dental insurance
• Employee assistance program
• Health insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• Day shift
• Monday to Friday
• Overtime

Application Question(s):

• Are you willing to work in El Monte?
• Are you willing to undergo a background check, in accordance with local law/regulations?

Experience:

• BlueCard Claims Processing: 5 years (Preferred)
• Medical terminology: 6 years (Preferred)
• Anthem and Basis systems: 3 years (Preferred)
• Group Medical Claims Processing: 5 years (Preferred)
• Medical Claims Processing: 5 years (Preferred)

Work Location: In person

Salary : $30