Claims Examiner II

Partnership HealthPlan of California; California; On-site; USD 43,000 - 52,000; Full time

Job summary

Partnership HealthPlan of California is seeking a Claims Examiner II to review, research, and resolve Medi-Cal claims within established production and quality standards, including manual processing.

You will route and track claims for review, generate provider communications as needed, and document actions taken, with autonomy and experience handling a wide range of claim types.

Qualifications

• High school diploma or equivalent; minimum six (6) months of medical billing and/or claims processing experience in an automated environment required.
• Knowledge of CPT and ICD-10 diagnosis coding preferred.

Responsibilities

• Reviews, researches, and resolves pended Medi-Cal claims across medical, hospital, ancillary, long-term care, encounter data, and batch claims.
• Routes claims to appropriate departments and staff for review; follows up to completion.
• Generates claims correspondence as needed and records daily production statistics.
• Reviews work audits and submits adjustments within the allotted time frame.
• Identifies trends in pending claims and reports to management; supports department needs.

Skills

Communication skills

Organization

Judgment

Attention to detail

Education

High school diploma or equivalent

Medical billing/claims processing experience (6 months)

Job description

Overview

To review, research, and resolve claims for all Medi-Cal claim types within established production and quality standards, including manual processing. Completes and processes claims and claims worksheets. Creates appropriate documentation that reflects the actions taken and status of the claim. Generates provider communication, such as letters, as necessary. Routes and tracks claims requiring review by other staff and departments, and processes when possible. Claims Examiner II is distinguished from Claims Examiner I by a higher level of autonomy and experience, as well as an ability to process a wider range of claim types.

Responsibilities

Essential Duties and Responsibilities

• Reviews, researches, and resolves pended claims for Medi-Cal types: medical, hospital, ancillary, long term care, encounter data, other coverage, and batch claims within established production and quality standards. Completes claims from the Batch Error Report and Batch Pass Report.
• Routes claims to appropriate Partnership departments and internal staff for additional review. Follows up and completes claims once response has been received.
• Follows established Partnership policies and procedures, Partnership Claims Operating Instruction Memorandums, State of California Medi-Cal Provider Manual guidelines, Title 22 regulations, and CMS guidelines when resolving pended claims.
• Generates claims correspondence as needed.
• Records daily production statistics and related activities on appropriate reports. Turns in all logs and reports to the Medi-Cal Claims Supervisor.
• Reviews all work audits in a timely manner and submits any adjustments and corrections within the allotted time frame.
• Supports Claims Department’s needs for resolving all pended claim types.
• Participates in special projects and assignments as required.
• Identifies and reports trends of pending claims that are increasing or processes that appear dated.
• Recognizes and gives feedback to management on procedure changes that would result in more efficient operations.
• Other duties as assigned.

Qualifications

Education and Experience

High school diploma or equivalent; minimum six (6) months of medical billing and/or claims processing experience in an automated environment required; or an equivalent combination of training and experience that demonstrates the ability to successfully perform the duties of the position.

Special Skills, Licenses and Certifications

Knowledge of CPT and ICD-10 diagnosis coding preferred.

Performance Based Competencies

Effective written and oral communication skills. Good organization skills. Ability to exercise good judgement within scope of authority and handle sensitive issues with tact and diplomacy. Ability to stay focused on repetitive work and meet production and quality standards. Ability to accurately complete tasks within established timelines. Consistently meet production standards without compromising quality on all tasks.

Work Environment And Physical Demands

Ability to use a computer keyboard. More than 80% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 5 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices;
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE

$ 31.45 - $ 37.74

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.