Healthcare Claims Specialist I

Western Growers; Fresno (CA); Presencial; USD 52 000 - 78 000; Tempo integral

Resumo da oferta

Western Growers is seeking a Claims Examiner I to review and process medical, dental, vision, and electronic claims in accordance with state, federal, and health plan guidelines. The role involves researching documents, verifying pricing, and ensuring timely payment while maintaining HIPAA safeguards.

You will interact with providers and internal stakeholders to resolve discrepancies and ensure accurate adjudication within standard production targets.

Qualificações

• Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, Blue Card, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, by calculating benefit due to approve or deny, based on SPD and within accepted corporate cycle timeframe.
• Analyze patient and medical records to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly.
• Examine claim files for accuracy: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation.
• Research through all vendor portals, including but not limited to Valenz, Occunet, Anthem
• Resolve benefit and eligibility issues that require detailed knowledge, support for customers within the claims processing, Company and ERISA guidelines. Process low to medium level claims, re-pricing corrections.
• Research, resolve and respond to all correspondence and internal communication (Ops Connect) related to electronic and paper claims as assigned.
• Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation. Utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
• Meet and maintain individual and department productivity and quality standards.

Responsabilidades

• Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, Blue Card, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, by calculating benefit due to approve or deny, based on SPD and within accepted corporate cycle timeframe.
• Analyze patient and medical records to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly.
• Examine claim files for accuracy: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation.

Conhecimentos

Claims Processing

HIPAA

Regulatory Compliance

Research & Analysis

Customer Service

Ferramentas

Valenz

Occunet

Anthem

Descrição da oferta de emprego

Western Growers is seeking a Claims Examiner I to review and process medical, dental, vision, and electronic claims in accordance with state, federal, and health plan guidelines. The role involves researching documents, verifying pricing, and ensuring timely payment while maintaining HIPAA safeguards.

You will interact with providers and internal stakeholders to resolve discrepancies and ensure accurate adjudication within standard production targets.