Claims Examiner I

This position operates on a hybrid work schedule. Candidate must reside in Los Angeles or Orange County.

About Us

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. We’re one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

About the Role

Under close supervision, Claims Examiner I processes non-complex paper or electronic claims, handling from inception to conclusion within established authority and guidelines. This position requires considerable interaction with clients, claimants on the phone, with management, other Claims Examiners, and other staff in the office. Consistent attendance at the office or home office location is inherently required.

Responsibilities

• Be familiar and comply with all company policies and procedures.
• Effectively manage a caseload of 50-150 claims a day.
• Initiate and conduct claim investigation in a timely manner.
• Achieve claims processing standards for accurate and timely claims adjudication.
• Maintain claims processing standards to meet performance appraisal goals.
• Determine compensability of claims and administer benefits, based upon product benefits and CMS guidelines.
• Manage medical treatment and medical billing, authorizing as appropriate, with requests for surgical treatment to be referred to supervisor prior to authorizing.
• Communicate with providers regarding claims issues.
• Compute and process payment.
• Finalize all claims and obtain authority as designated.
• Maintain documentation in file to reflect the status of and work being performed on the file.
• Communicate appropriate information promptly to the client to resolve claims efficiently.
• Involve supervisory staff when appropriate.
• Adhere to all Company policies and procedures.
• Participate in audits and file reviews, as needed.
• Perform other duties as assigned, including assisting Document Processing Associate and mailroom tasks.

Requirements

• Associate degree. Bachelor’s degree in related field preferred.
• One (1) year related experience; or equivalent combination of education and experience.

Skills

• Technical knowledge of statutory regulations and medical terminology.
• Familiar with CMS claims payment and billing guidance.
• Knowledge of CPT, HCPCS, and ICD-10 diagnosis codes.
• Strong analytical skills, including the ability to analyze and organize data.
• Strong attention to detail.
• Excellent organizational, oral presentation, and written and verbal communication skills.
• Proficiency in MS Office products, including PowerPoint, Excel, and Word.

Pay

$27.00 to $32.00 per hour. Salary ranges posted are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

Physical & Working Environment

• Must be able to travel when needed or required.
• Ability to operate a keyboard, mouse, phone, and perform repetitive motion (keyboard); writing (note-taking).
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
• Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.
• Work is performed in an office environment and/or remotely.
• The job involves frequent contact with staff and public.
• May occasionally be required to work irregular hours based on the needs of the business.