CLAIMS EXAMINER I MSO

NORTH EAST MEDICAL SERVICES; Burlingame (CA); On-site; USD 43,000 - 62,000; Full time

Benefits offered by this job

Free medical, dental and vision for员工及

Company 401(k) contribution

Competitive benefits

Job summary

NORTH EAST MEDICAL SERVICES in Burlingame, CA is seeking a Claims Examiner to review, audit, and adjudicate professional claims. The role requires handling a high-volume workload, ensuring compliance with Medi-Cal and Medicare guidelines, and supporting audits and system upgrades.

The position emphasizes accurate data entry, strong English communication, and a detail-oriented approach to resolving claims issues in a timely manner.

Qualifications

• Completion of a 2-year degree from an accredited university, or relevant work experience in claims processing.
• Two years’ experience in health insurance claims processing, examination, and adjudication preferred.
• Excellent data entry skills required.
• Working knowledge of Medi-Cal and Medicare Advantage programs preferred.
• Strong understanding of HIPAA and related regulations is preferred.

Responsibilities

• Perform daily examination, auditing and adjudication of submitted professional claims per criteria and guidelines.
• Meet a quantitative production standard of 750 claims per week.
• Provide feedback on system testing and improvements.
• Review pre-payment claims reports and correct processing errors before payment cycles.
• Identify in-house billing errors and coordinate corrections with supervisors and billing manager.
• Identify claims payment or system issues and coordinate resolutions with IT teams.
• Respond to provider inquiries about claims adjudication, denial and payment status.
• Assist in pre- and post-audit activities for health plan delegation oversight.
• Perform other duties as required by management.

Skills

Data entry

Analytical skills

Problem solving

English communication

Education

2-year degree or relevant work experience

Job description

Job Details

Job Location: Burlingame, CA 94010

Salary Range: $38.00 - $38.00 Hourly

The Claims Examiner is responsible for the daily review, audit, examination, investigation and adjudication of professional claims. Must exceed qualitative standard and meet quantitative production standard. Assist Claims Supervisor with health plan delegation oversight audits, MSO management reports, and other special projects as needed.

ESSENTIAL JOB FUNCTIONS:

• Perform the daily examination, auditing and adjudication activities to submitted professional claims based on established utilization criteria, Medi-Cal and/or Medicare guidelines, member’s Evidence of Benefit, and policies and procedures outlined in the MSO Claims Manual.


• Must meet quantitative production standard of 750 claims per week.


• Provides feedback on testing system upgrades and enhancements.


• Responsible for the daily review of simple pre-payment claims reports. Identify processing errors and make corrections prior to the weekly FFS payment cycle.


• Identify NEMS in-house billing errors and communicate with MSO Claims Supervisor and NEMS Billing Manager for correction.


• Identify claims payment errors and/or system configuration flaws during day-to-day operation, report to department manager/supervisor and MSO System Configuration team to correct/resolve them.


• Respond to first-level provider inquiries related to claims adjudication, denial and payment status and handle member billed issues when arise.


• Assist in all pre and post audit activities for health plan’s delegation oversight audits.


• Performs other job duties as required by manager/supervisor and NEMS Management Team.

Qualifications

• Completion of a 2-year degree from an accredited University, may be substituted with relevant work experience in healthcare medical claims processing and examination field.


• Two years’ experience in health insurance claims processing, examination, and adjudication preferred.


• Excellent data entry skills required.


• Working knowledge of managed care and/or healthcare claim reimbursement or medical billing in Medi-Cal and Medicare Advantage program preferred.


• Working knowledge of State/Federal healthcare compliance requirements (HIPAA, AB1455, and ICE standards), particularly DHCS/Medi-Cal and/or CMS/Medicare guidelines preferred.


• Working knowledge of medical terminology, standard code sets, and claim forms preferred.


• Strong English communication skills with strong analytical and problem-solving skills.


• Ability to self-manage in a detail-oriented environment.


• Ability to operate PC based software programs or automated database management systems preferred.


• Good organization and prioritization skills, outstanding in time management.

LANGUAGE

• Must be able to fluently speak, read and write English.


• Fluent in other languages are an asset.

STATUS

• This is an FLSA NON-exempt position.


• This is not an OSHA high-risk position.


• This is a Full Time position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS

Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).