Claims Specialist - Complex Adjustments & Analysis

Partnership HealthPlan of California; California; On-site; USD 50,000 - 62,000; Full time

Job summary

Partnership HealthPlan of California is seeking a claims examiner to support the Claims Department in maintaining pended claims and adjustments within established guidelines. You will review and process complex claims, participate in special projects, and assist in training staff to ensure accuracy and efficiency.

Responsibilities include researching adjustment requests, maintaining reports, and recording daily production statistics.

Qualifications

• Minimum three (3) years claims examining experience; or Partnership claims examining experience and completion of Partnership claims training; or equivalent combination of education and experience; College course work in business or related field preferred.
• Familiarity with Medi-Cal and/or managed care claims processing.
• Knowledge of CPT, HCPC procedure coding, and ICD-9 diagnostic coding.
• Knowledge of Partnership Claim Policy and Procedures, EDS provider manual guidelines, Title 22 regulations and any other required policies, procedures, regulations, and manuals.
• Typing speed 30 wpm and proficient use of 10-key calculator.
• Valid California driver's license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

Responsibilities

• Researches and processes claim adjustment requests.
• Participates in special claim adjustment projects as assigned.
• Assists in maintaining pended claim reports and files within established department guidelines and program policies.
• Performs claims examining functions as assigned.
• Performs claims customer service functions as assigned.
• Assists in training claims staff as needed.
• Monitors efficiency of operations and provides feedback to management on possible effective procedure changes.
• Records daily production statistics and related activities on appropriate reports; turns all logs and reports into the Claims Supervisor.
• Other duties as assigned.

Skills

Claims examining

Medi-Cal knowledge

Managed care claims processing

CPT/HCPC/ICD-9 coding

Typing 30 wpm

10-key calculator

Education

College coursework in business or related field

Job description

Partnership HealthPlan of California is seeking a claims examiner to support the Claims Department in maintaining pended claims and adjustments within established guidelines. You will review and process complex claims, participate in special projects, and assist in training staff to ensure accuracy and efficiency.

Responsibilities include researching adjustment requests, maintaining reports, and recording daily production statistics.