Lead - Claims Examiner

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

This is a hybrid role where the expectation is to work both in office and at home on a weekly basis.

Target pay range: $25.00 - $30.00 per hour. Actual compensation will be determined based on geographic location, experience, and other job-related factors.

About the role

We are seeking a highly motivated Lead - Claims Examiner to enable us to continue to scale in the healthcare industry. This role will report to the Sr. Manager - Claims.

Responsibilities

• Monitor and review work of all Claims Quality, Appeals, and Recovery staff to identify additional training needs and ensure compliance with department quality/production standards.
• Provide performance feedback and identify developmental opportunities for Claims Quality, Appeals, and Recovery staff.
• Monitor and review claims audit and transaction reports; identify claims error trends and implement controls/changes to minimize incorrect claims adjudication.
• Coordinate potential recovery efforts with Company Accounting and coordinate potential physician education opportunities with Company Physician Services.
• Work closely with other Company departments to ensure all areas supporting claims meet appropriate claims quality goals.
• Ensure all legal, regulatory, and policy requirements are met by staying informed of changes and implementing necessary controls/programs.
• Collaborate with the Claims QA and Training Specialist and claims lead to ensure Claims Representatives thoroughly understand Company claims adjudication policies and procedures.
• Coordinate provider contract, health plan benefit/DOFR, and system rules configuration testing with the Business Applications Configuration team.
• Ensure accurate reporting and timely submission of quarterly PDR timeliness reports.
• Work with Company departments to implement controls minimizing claims overpayments and identify physician education opportunities with Network Management.
• Work closely with other Company departments, specifically the Claims QA and Training Specialist, to communicate findings of recovery audits and facilitate accurate adjudication of claims.

Requirements

• Bachelor’s degree in a relevant field or equivalent combination of education and progressively responsible experience.
• At least 5 years of claims experience working for either a Medical Group, IPA, MSO, or Health Plan.
• Advanced knowledge of and working experience with healthcare coding conventions such as ICD-10, CPT, and HCPCS.
• Thorough knowledge of medical claim processing procedures/systems, auditing, and a thorough understanding of claim protocols, industry standards, and CMS regulations as they relate to claims payment and compliance.
• Knowledge of claims processing systems configuration and architecture to facilitate troubleshooting of claims transaction-related issues.

Skills

• EZ Cap knowledge.