Claims Examiner II

A Claims Examiner is responsible for analyzing and the adjudication of medical claims as it relates to managed care. Performs payment reconciliations and/or adjustments related to retroactive contract rate and fee schedule changes. Resolve claims payment issues as presented through Provider Dispute Resolution (PDR) process or from claims incident/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payments. Generates and develop reports which include but not limited to root causes of PDRs and Incidents. Collaborates with other departments and/or providers in successful resolution of claims related issues.

• Process medial claims, professional and institutional as it relates to the appropriate Federal and State regulations based on the member’s Line of Business; Medicare, Medi-Cal, Commercial, PACE Lines of Business.
• Read and interpret DOFRs as it relates to the claim in order to ensure that group is financially at risk for payment.
• Read and interpret provider contracts to ensure payment/denial accuracy.
• Read and interpret Medi-Cal and Medicare Fee Schedules.
• Correct claims payment/denial errors identified by the Claims Auditor prior to a check run.
• Must maintain an error accuracy of under 3%.
• Communicate with Claims Management for any issues relating to provider, fee schedule, eligibility, authorization, or system issues.
• Assist in the creation of any business rules and training in order for the Claims Department to become more efficient and accurate.
• Coordinate with the Recovery Department for any identified overpayments.
• Attend monthly departmental meetings and provide feedback when requested.
• Other duties as assigned.

• HS Diploma or GED
• 3+ years of Claims Processing experience in a managed care environment.
• Must be knowledgeable of Medi-cal regulations.
• Preferred knowledge of Medicare and Commercial rules and regulations.
• Knowledge of medical terminology.
• Must have an understanding to read and interpret DOFRs and Contracts.
• Must have an understanding how to read a CMS-1500 and UB-04 form.
• Must have strong organizational and mathematical skills.