What are the responsibilities and job description for the Claims Examiner position at Preferred IPA of California?
GENERAL SUMMARY
The Claims Examiner position is primarily responsible for the accurate and timely adjudication of paper and/or electronically formatted claims received in the CMS 1500 and/or UB-04 format. The Examiner processes all claims and applicable claims correspondence in accordance with Medicare and Medi-Cal regulatory guidelines, contract provisions and established policies and procedures. Additionally, s/he is responsible for consistently meeting accuracy and productivity targets outlined in the department's performance standards.
SKILLS REQUIRED
- Minimum of 4 years medical claims payment experience in an HMO environment (i.e. MSO, IPA or health plan)
- Strong knowledge of Medicare and Medi-Cal managed care claims processing and compliance guidelines.
- Experience with CPT-4, ICD-10CM, RBRVS, ASA and HCPCS as well as in depth understanding of Medicare and Medi-Cal guidelines that apply to COB and Medicare Secondary Payer.
- Extensive familiarity and experience in plan benefit and co-payment determination, division of financial responsibility determination, claims policies and procedures and adjudication processes and claim review and analysis involving NCCI rules.
- Extensive working knowledge of reimbursement methodologies of professional claims including injectable drugs.
- Must be detail-oriented, attentive, organized, and able to follow directions.
- Ability to work independently utilizing company established processes.
- Ability to meet deadlines and maintain department quality standards.
- Ability to interact well with providers calling regarding claim status.
- Ability to interact well with fellow employees and supervisors and be a team player.
- Strong work ethics and professionalism.
- Intermediate computer skills including Microsoft Word, Excel and Internet navigation.
Salary : $18 - $24