Job Details

  • Position Number: 2055713
  • Location: Orange, CA
  • Position Type: Business and Financial Management

Claims Examiner, Sr.

Job Description
This position is responsible for analyzing and validating claims elements and claims processing. The incumbent is responsible for adhering to the regulatory and internal guidelines in conjunction with CalOptima policies and procedures related to claims adjudication. Senior level examiner is responsible to adjudicate complex claims, requiring additional research or problem solving.

Position Responsibilities:
  • Processes both professional and institutional claims types.
  • Performs thorough review of pending claims for billing errors and or questionable billing practices that mighty include duplicate billing and unbundling of services.
  • Responsible for manually correcting system generated errors prior to final claims adjudication.
  • Processes claims based upon CalOptima contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and CalOptima policies and procedures
  • Analyzes, validates Medi-Cal pricing, researches, adjusts and adjudicates claims, reviews services for accurate charges; utilizing billing code sets and/or authorization guidelines as reference.
  • Processes claims based upon contractual and/or CalOptima agreements, involving the use of established payment methodologies, Division of Financial Responsibility.
  • Alerts manager or supervisor of more complex issues that arise.
  • Processes claim exception reports as assigned.
  • Maintains quality and productivity standards as set by management.
  • Other duties and projects as assigned by management.

Required Skills
  • Meet and maintain established quality and production standards.
  • Work independently and as part of a team.
  • Develop and maintain effective working relationships with all levels of staff and providers.
  • Handle multiple tasks and meet deadlines.
  • Utilize and access computer and appropriate software (e.g. Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.

Experience & Education:
  • High School graduate or equivalent required.
  • 3 years of experience processing online claims in a managed care and/or PPO/indemnity environment required.
  • Experience that demonstrates solid customer service skills required.
  • Experience processing Medi-Cal claims preferred.

Knowledge of:
  • Revenue codes and billing code sets, i.e. Current Procedural Terminology (CPT), Healthcare Common Procedural Coding System, International Classification Diseases-10 (ICD-10) Codes and medical terminology.
  • Industry pricing methodologies, such as Resource Based Relative Value Scale, Medi-Cal Fee Schedule, etc.
  • Benefit interpretation and administration.
  • Medicare/Medi-Cal guidelines and regulations.

Grade: I


Job Location: Orange, California, United States
Position Type: Full-Time/Regular

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