Claims Examiner II- Bakersfield 1.1

Universal Healthcare IPA, Inc.; Bakersfield (CA); On-site; USD 29,000 - 37,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

PTO

Floating holidays

Simple IRA 3% match

Life insurance

Employee assistance program

Job summary

Universal Healthcare IPA, Inc. in Bakersfield, CA seeks a Claims Examiner II to adjudicate medical claims (CMS 1500 and CMS 1450/UB04) in our claims system.

This full-time, non-exempt, hourly role requires accurate data entry, knowledge of CPT/HCPCS/ICD-10, and adherence to contracts and paid-time policies. The position emphasizes independent work, timely processing, and collaboration with Eligibility, Member Services, UM, providers, and health plans.

Qualifications

• High School diploma or equivalent.
• Strong knowledge of professional and institutional claim processing procedures.
• Familiarity with CPT, HCPCS, ICD-10, ASA, Revenue Codes.
• Proficiency in MS Excel, Word, and Outlook.
• Ability to type 40-50 Words per minute (WPM).
• One or more years working in a healthcare or related business environment preferred.

Responsibilities

• Review and process claims following policies and criteria.
• Evaluate payments based on eligibility, benefits, authorizations, coding, and contracts.
• Apply correct terms to claims per contracts and health plan rules.
• Process denials accurately and generate denial letters.
• Meet timeliness and quality standards in claim processing.
• Make payment or denial decisions while handling confidential information.
• Refer misaligned claims to the UM department.
• Coordinate with Eligibility, Member Services, UM, providers and health plans.
• Work independently following established policies and procedures.

Education

High School diploma

Tools

CMS 1500

CMS 1450/UB04

Billing system

Job description

Description

Location: Bakersfield, CA. (Onsite)

Classification: Full-Time

This position is non-exempt and will be paid on an hourly basis.

Schedule:

Monday- Universal Healthcare MSO's standard operating hours are Monday through Friday, from 8:00 a.m. to 5:00 p.m. Pacific Time. Unless otherwise specified, all employees are expected to work their assigned schedules and remain available during these operational hours.

Benefits:

• Medical
• Dental
• Vision
• Paid Time Off (PTO)
• Floating Holiday
• Simple IRA Plan with a 3% Employer Contribution
• Employer Paid Life Insurance
• Employee Assistance Program

Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $21.40 and $26.74. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

Position Summary:

As the Claims Examiner ll, your primary responsibility will be to adjudicate medical claims within claims transaction system. Verifying information is accurately captured and complete in database. You will process both professional (CMS 1500) and institutional (CMS 1450/UB04). During this verification process, the system will prompt you to conduct audits on specific fields to ensure accuracy and completeness for each claim in the batch.

Job Duties and Responsibilities:

• Follow written criteria, policies, and procedures to thoroughly review and process claim.
• Evaluate claims for appropriateness of payment, considering factors such as eligibility, benefits, authorizations, coding, compliance, contracted payment terms or relevant fee schedule, and health plan contracts.
• Stay informed about annual changes in contracts and apply the correct terms to claims, ensuring adherence to contracted payment terms and health plan agreements.
• Ensure accurate and proper denial processing in the system for claims deemed inappropriate for payment, facilitating correct letter generation.
• Consistently meet internal, external, and governmental timeliness standards in processing claims to ensure prompt and efficient service delivery.
• Exercise the freedom to make decisions regarding payment or denial of medical services, handling sensitive and confidential information with utmost discretion.
• Refer claims and accompanying documentation to the Utilization Management (UM) department if they do not align with department policy guidelines.
• Interact with various stakeholders, including Eligibility, Member Services, UM, providers, Health Plans, and applicable staff, as needed for claim resolution.
• Maintain compliance with established production and quality standards, ensuring accuracy and efficiency in claim processing.
• Work independently on assigned tasks and activities based on established policies and procedures, demonstrating autonomy and accountability.
• Other related duties as assigned.

Requirements

Qualifications

• High School diploma or equivalent.
• Strong knowledge of professional and institutional claim processing procedures,
• including COB (Coordination of Benefits)/TPL (Third Party Liability)/WC.
• Familiarity with CPT, HCPCS, ICD-10, ASA, Revenue Codes, etc.
• Performs high volume data entry.
• Strong background with system automation of claims processes and workflows.
• Familiar with office equipment (including a photocopy machine, scanner, facsimile machine, etc.)
• Proficiency in MS Excel, Word, and Outlook.
• Ability to type 40-50 Words per minute (WPM) or 6,000 8,000 Keystrokes per Hour
• One or more years working in a healthcare or other related business environment: experience in medical billing services and/or managed care environment preferred.

(KSPH).

Physical Requirements & Working Conditions

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of this position.