Claims Examiner II

Partnership HealthPlan of California; Fairfield (CA); On-site; USD 41,851 - 50,227; Full time

Job summary

Partnership HealthPlan of California is seeking a Claims Examiner II to review and resolve Medi-Cal claims while adhering to established standards. This role handles various claim types and requires strong communication and organizational skills.

The ideal candidate will have at least one year of experience in Medi-Cal billing and claims examination, along with knowledge of related regulations and processing requirements. The position offers a hiring range of $30.38 to $36.46 per hour.

Qualifications

• High school diploma or equivalent required.
• Minimum one year in Medi-Cal billing and claims examining experience essential.
• Knowledge of CPT and ICD-10 preferred.

Responsibilities

• Review and resolve Medi-Cal claims for various types.
• Route claims for review and follow up as needed.
• Generate claims correspondence as required.

Skills

Effective written and oral communication skills

Good organization skills

Knowledge of claims processing

Medi-Cal billing knowledge

CPT knowledge

ICD-10 knowledge

Education

High school diploma or equivalent

Minimum one (1) year in Medi-Cal billing and/or claims examining experience

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

• Reviews, researches, and resolves pended claims for Medi-Cal types: medical, ancillary, long term care, CHDP, 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 to request 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 one (1) year in Medi-Cal billing and/or claims examining experience in an automated environment.

Special Skills, Licenses and Certifications

Effective written and oral communication skills. Good organization skills. Knowledge of claims processing and/or Medi-Cal billing, CPT, and ICD-10 knowledge preferred.

Performance Based Competencies

Ability to effectively 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 meets production standards without compromising quality on all tasks.

Work Environment And Physical Demands

Ability to use a microcomputer keyboard. More than 95% 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; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$30.38 - $36.46

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.