Claims Examiner (Remote/Hybrid work available)
Imperial Health Plan of California, Inc. · Pasadena, CA · 4 mo ago
On-siteFinanceFull-time
Essential Job Functions
- Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e. co-payment, deductible, etc.
- Review and process facility (UB-04) and professional claims (CMS-1500).
- Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups’ and company policies and procedures.
- Process Medicare member claims based on DMHC and DHS regulatory legislature.
- Respond to and resolve provider and health plan claims inquiries and give resolution in a timely manner.
- Review services for appropriateness of charges and apply authorization guidelines during claims processing.
- Monitor and track age, pended, and open reports to maintain timeliness in claims processing based on individual work allocation report.
Qualifications
- At least 2 years of applicable healthcare claims adjudication experience within the managed care industry.
- Experience with ICD-9, HCPCS, CPT coding, APC, ASC and DRG pricing, CMS, DMHC regulations, facility and professional claim billing practices required.