Claims Examiner

Unilogic Healthcare Management, LLC.; Cypress (CA); On-site; USD 55,000 - 75,000; Full time

Job summary

Unilogic Healthcare Management, LLC. is seeking a Claims Examiner to process medical claims efficiently and accurately, determining financial responsibility among groups, health plans, and hospitals.

The role requires adjudicating various claim types and adhering to regulatory guidelines. Candidates should have at least two years in claims adjudication, knowledge of ICD9/CPT/HCPCS, and experience in a Managed Care/IPA environment; EZ-CAP knowledge is a plus.

Qualifications

• High School Diploma or equivalent.
• At least two years of claims adjudication experience preferred.
• Knowledge of medical terminology, ICD9 and CPT/HCPCS codes required, including ten-key calculator, computer, and light typing skills 35wpm.
• Processing experience in a Managed Care/IPA environment preferred.
• EZ-CAP knowledge preferred.

Responsibilities

• Process medical claims to determine financial responsibility among groups, health plans, and contracted hospitals.
• Adjudicate all types of claims (Contracted, Non-contracted, 1500 or UB forms) accurately and timely.
• Adhere to regulatory processing guidelines and federal/state healthcare plan laws.
• Respond promptly to claims-related inquiries from Management.
• Participate in special projects as assigned by Management.
• Perform other job-related duties as assigned.

Skills

Multi-tasking

Attention to detail

Problem solving

Independent work

Education

High School Diploma

Tools

Ten-key calculator

Computer

Typing 35 wpm

Job description

The Claims Examiner is responsible for processing medical claims in an efficient, cost-effective, and timely manner.

Responsible for determining financial responsibility between group, health plans and contracted hospitals for accurate processing of claims.

Responsible for preparing, researching, analyzing, pre-coding and the adjudication of all types of claims (Contracted providers, Non-contracted, 1500 or UB claims forms.

Recognize the difference between Shared Risk and Full Risk claims.

Processes/adjudicates medical claims according to regulatory processing guidelines and in compliance with all federal and state healthcare plan laws and regulations.

Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations.

Knowledge of Coordination of Benefits.

Processing standard of 10 claims or more per hour with a 99% level of accuracy.

Prompt and accurate response to claims related questions from Management.

Participate in special projects as assigned by Management.

Perform other job related duties as assigned.

Qualifications

High School Diploma or equivalent. Course work and knowledge of medical terminology preferred.

At least two years of claims adjudication experience preferred.

Knowledge of medical terminology, ICD9 and CPT/HCPCS codes required, including ten-key calculator, computer, and light typing skills 35wpm.

Processing experience in a Managed Care/IPA environment preferred.

EZ-CAP knowledge preferred.

Ability to multi-task in an efficient, thorough, and prioritized manner; to work quickly, accurately, and independently; and, to anticipate needs and solve problems.