Medical Claims Analyst — Payment, Compliance & Research

NALHE; Downey (CA); Vor Ort; USD 50.000 - 65.000; Vollzeit

Zusammenfassung

NALHE is seeking a claims processor in Downey, CA to review and determine payments for medical claims, using ICD-9 and CPT codes as needed. The role requires staying compliant with CMS, DMHC, DHS, and NCQA rules and procedures.

You will assess medical necessity, coordinate benefits, and identify trends to improve accuracy and efficiency in the claims cycle. Strong attention to detail and regulatory knowledge are essential.

Qualifikationen

• Reviews claims and makes payment determinations.
• Ensures compliance with CMS, DMHC, DHS and NCQA requirements.
• Utilizes ICD-9 and CPT coding as required.

Aufgaben

• Reviews claims and determines payment with authorization limit up to $9,999 per claim.
• Investigates medical appropriateness and coordination of benefits issues.

Kenntnisse

Claims processing

Payment determination

ICD-9/CPT coding

Regulatory compliance

Jobbeschreibung

NALHE is seeking a claims processor in Downey, CA to review and determine payments for medical claims, using ICD-9 and CPT codes as needed. The role requires staying compliant with CMS, DMHC, DHS, and NCQA rules and procedures.

You will assess medical necessity, coordinate benefits, and identify trends to improve accuracy and efficiency in the claims cycle. Strong attention to detail and regulatory knowledge are essential.