CLAIMS EXAMINER I MSO

About the role

The Claims Examiner is responsible for the daily review, audit, examination, investigation, and adjudication of professional claims. The role requires exceeding qualitative standards and meeting quantitative production standards. Additionally, the Claims Examiner assists the Claims Supervisor with health plan delegation oversight audits, MSO management reports, and other special projects as needed.

Responsibilities

• Perform daily examination, auditing, and adjudication of submitted professional claims based on established utilization criteria, Medi-Cal and/or Medicare guidelines, member’s Evidence of Benefit, and policies and procedures outlined in the MSO Claims Manual.
• Meet quantitative production standard of 750 claims per week.
• Provide feedback on testing system upgrades and enhancements.
• Conduct daily review of simple pre-payment claims reports.
• Identify processing errors and make corrections prior to the weekly FFS payment cycle.
• Identify NEMS in-house billing errors and communicate with MSO Claims Supervisor and NEMS Billing Manager for correction.
• Identify claims payment errors and/or system configuration flaws during day-to-day operations, report to department manager/supervisor and MSO System Configuration team for resolution.
• Respond to first-level provider inquiries related to claims adjudication, denial, and payment status, and handle member-billed issues as they arise.
• Assist in all pre and post audit activities for health plan’s delegation oversight audits.
• Perform other job duties as required by manager/supervisor and NEMS Management Team.

Requirements

• Completion of a 2-year degree from an accredited University, which may be substituted with relevant work experience in healthcare medical claims processing and examination.
• Two years’ experience in health insurance claims processing, examination, and adjudication preferred.
• Excellent data entry skills required.
• Working knowledge of managed care and/or healthcare claim reimbursement or medical billing in Medi-Cal and Medicare Advantage programs preferred.
• Working knowledge of State/Federal healthcare compliance requirements (HIPAA, AB1455, and ICE standards), particularly DHCS/Medi-Cal and/or CMS/Medicare guidelines preferred.
• Working knowledge of medical terminology, standard code sets, and claim forms preferred.
• Strong English communication skills with strong analytical and problem-solving skills.
• Ability to self-manage in a detail-oriented environment.
• Ability to operate PC-based software programs or automated database management systems preferred.
• Good organization and prioritization skills, outstanding in time management.

Qualifications

• Must be able to fluently speak, read, and write English.
• Fluency in other languages is an asset.

This is an FLSA non-exempt position and is not an OSHA high-risk position.