Job Abstract

Responsibilities:

Parameters of the provider's contract obligations.
Audit claims processing quality, develops, maintains and runs standard reports
Assist the Claims Supervisor/Director in reviewing the quality auditing tracking/reporting (financial and procedural)
Coordinating with various departments to resolve disputes or issues
Maintain the Claims department workflow
Review and process hospital claims and complicated claims to assist claims examiners I, and II
Claims processing to ensure quality (in/out patient hospital claims, Medi-cal, Commercial, and Medi-care claims)
Review auto adjudication of claims
Review carve-outs in the Division of Financial Responsibility (DOFR)
Review and process reports and work with management and claims unit
Assist the Claims Manager in reviewing the quality auditing tracking/reporting
Assist with training/supporting the claims team
Recommend and assist in the development of process improvements
Coordinating with various departments to resolve disputes or issues
Able to process a claim and assist the team by answering questions and providing support
Prepare for check runs
Other duties may be assigned as needed to assist the AMM team
Basic policies and operations of health care insurance plans.
Federal, State and local rules and regulations as they relate to claims processing.
Modern office practices and procedures.
Business mathematical computation.
Computer application related to the work.

Required Skills and Abilities

High School Diploma or GED, some college preferred
3-5 years of claims examiner experience processing professional and facility claims
Strong analytical and problem solving skills are necessary
Know the industry guidelines for all LOBs
Proficient with medical terminology, CPT, Revenue codes, ICD-10,
Medicare and Medi-Cal claims adjudication experience required.
Knowledge of claims processing rules, managed care benefits and adjudication
Strong analytical skills and problem-solving skills are necessary.
Familiarity with Medicare guidelines and ICE compliance guidelines
Experience with the handling of claims in a managed care business (HMO)
Extensive knowledge of claims processing and claims data analysis
Experience with EZ-Cap and Encoder Pro preferred
Must be familiar with Microsoft Office (Word, Excel, Outlook)

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance.