The Claims Examiner II is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes: Processing claims for all lines of business. Processing all claims type as needed. Monitoring itemized billings for excessive charges and duplications ensuring all work meets quality guidelines and is performed within acceptable time frames. Reviewing claims for required information, pending claims when necessary, maintain... more details
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Job Summary
The Claims Examiner II is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes:
Processing claims for all lines of business. Processing all claims type as needed. Monitoring itemized billings for excessive charges and duplications ensuring all work meets quality guidelines and is performed within acceptable time frames. Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated. Meeting and exceeding performance measurements for Claim Examiners as required by the department to meet regulatory compliance. Assisting management with onsite training as needed. Assisting Claims Examiner III as needed for special requests.
Duties
Process incoming claims: Determine correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions; Process all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner; Document provider claims/billing forms to support payments/decisions. Negotiate reimbursement amounts for out-of-network claims; Identify dual coverage, Potential third party savings/recovery; Maintain department databases used for report production and tracking on-going work; Claims are processed within the contractual and/or regulatory time frames within or less than 45 working days and as supported by the departmental policies. (60%)
Perform special projects and ad-hoc reporting as necessary. Projects are complete and reports are generated within the specific time frame agreed upon at the time of assignment. (15%)
Assist management with in-house and on-site training as offered to employees, contracted partners and providers. (5%)
Work with internal departments to resolve issues preventing claims processing or enhancing processing capabilities. May assist in testing, changing, analyzing and reporting of specific enhancements. (5%)
Attend meetings as required. Claims Department/Operations Division is represented at internal and external meetings. (5%)
Perform other duties as assigned. (10%)
Duties Continued
Education Required
High School Diploma/or High School Equivalency Certificate
Education Preferred
Associate's Degree
Experience
Required:
At least 1 year of healthcare claims processing experience in a managed care environment.
Preferred:
Previous Medi-Cal or Medicare claims processing experience.
Skills
Required: Ability to operate PC-based software programs or automated database management systems.
Strong communication skills with excellent analytical and problem solving skills.
Ability to self-manage in a fast-paced, detail-oriented environment.
Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials (Provider Dispute Resolution (PDR), Current Procedural Terminology (CPT), International Classification of Diseases (ICD-10), and Healthcare Common Procedure Coding System (HCPCS)), and complete product and Coordination Of Benefits (COB) knowledge.
Moderate knowledge of Microsoft Word and Excel.
Preferred:
Knowledge of AB1455 regulations.
Licenses/Certifications Required
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
Job Abstracts is an independent Job Search Engine. Job Abstracts is not an agent or representative and is not endorsed, sponsored or affiliated with any employer. Job Abstracts uses proprietary technology to keep the availability and accuracy of its job listings and their details. All trademarks, service marks, logos, domain names, and job descriptions are the property of their respective holder. Job Abstracts does not have its members apply for a job on the jobabstracts.com website. Additionally, Job Abstracts may provide a list of third-party job listings that may not be affiliated with any employer. Please make sure you understand and agree to the website's Terms & Conditions and Privacy Policies you are applying on as they may differ from ours and are not in our control.
Welcome to Job Abstracts
We would like to take a second to Welcome You to Job Abstracts, the nation’s largest Pure Job Board. With over 3.1 million job listings from 15,000+ Companies & Organizations, we help job searchers find careers that match their interests. As an anonymous user, you have probably discovered how easy our system is to use. However, you have just scratched the surface of what we can offer.
We encourage you to Register so you can use our most powerful features: searching with multiple terms, setting up multiple locations, establishing favorite companies, and accessing your search history. If you find a job you like, you can apply directly for it, and then, keep notes on it. We will also keep a lookout for jobs that match your search terms and email you when we find something you may like.
You can register for free and the system is free to use. If you like our system so far, click on Register and unlock the power required by serious job searchers.
Any time you conduct a search, the system shows you job matches, ranked by their Relevance Score (RS).
The score is calculated by a proprietary algorithm that uses Intelligent Machine Learning.
The Relevance Score tells you how well the job opportunity matches your search term or terms.
When not logged in, the system is limited to one search term. Scores for single term matches are usually lower.
When you register, log in, and set up multiple terms prioritized by importance, the jobs found for you will receive a much higher Relevance Score.