Claims Examiner II

About the Role

To review, research, and resolve claims for all Medi-Cal claim types within established production and quality standards, including manual processing. The Claims Examiner II is distinguished from Claims Examiner I by a higher level of autonomy and experience, as well as an ability to process a wider range of claim types.

Responsibilities

• Reviews, researches, and resolves pended claims for Medi-Cal types: medical, ancillary, long term care, CHDP, encounter data, other coverage, and batch claims within established production and quality standards.
• Completes claims from the Batch Error Report and Batch Pass Report.
• Routes claims to appropriate Partnership departments and internal staff for additional review.
• Follows up and completes claims once response to request has been received.
• Follows established Partnership policies and procedures, Partnership Claims Operating Instruction Memorandums, State of California Medi-Cal Provider Manual guidelines, Title 22 regulations, and CMS guidelines when resolving pended claims.
• Generates claims correspondence as needed.
• Records daily production statistics and related activities on appropriate reports.
• Turns in all logs and reports to the Medi-Cal Claims Supervisor.
• Reviews all work audits in a timely manner and submits any adjustments and corrections within the allotted time frame.
• Supports Claims Department’s needs for resolving all pended claim types.
• Participates in special projects and assignments as required.
• Identifies and reports trends of pending claims that are increasing or processes that appear dated.
• Recognizes and gives feedback to management on procedure changes that would result in more efficient operations.
• Completes and processes claims and claims worksheets.
• Creates appropriate documentation that reflects the actions taken and status of the claim.
• Generates provider communication, such as letters, as necessary.
• Routes and tracks claims requiring review by other staff and departments, and processes when possible.
• Other duties as assigned.

Requirements

• High school diploma or equivalent.
• Minimum one (1) year in Medi-Cal billing and/or claims examining experience in an automated environment.

Skills

• Effective written and oral communication skills.
• Good organization skills.
• Knowledge of claims processing and/or Medi-Cal billing, CPT, and ICD10 knowledge preferred.
• Ability to effectively exercise good judgement within scope of authority and handle sensitive issues with tact and diplomacy.
• Ability to stay focused on repetitive work and meet production and quality standards.
• Ability to accurately complete tasks within established timelines.
• Consistently meets production standards without compromising quality on all tasks.

Work Environment and Physical Demands

• Ability to use a microcomputer keyboard.
• More than 95% of work time is spent in front of a computer monitor.
• When required, ability to move, carry, or lift objects of varying size, weighing up to 5 lbs.

Pay

Hiring range: $31.4512 - $37.74 per hour.