Senior Medicare Claims Specialist

Verda Healthcare Inc; Huntington Beach (CA); Presencial; USD 39 000 - 44 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

401(k)

Paid time off

Health insurance

Dental Insurance

Vision insurance

Life insurance

Resumo da oferta

Verda Healthcare, Inc. in Huntington Beach, CA is seeking a Senior Claims Examiner to review, analyze, and adjudicate complex claims across professional, institutional, inpatient, outpatient, and Medicare Advantage lines.

The role requires expertise in CMS regulations, provider contracts, and reimbursement methodologies, with a focus on accuracy, quality, and timely processing. The ideal candidate will have 5+ years of healthcare claims processing experience, strong communication skills, and

Qualificações

• Minimum 5 years of healthcare claims processing experience.
• Minimum 2 years adjudicating Medicare Advantage claims preferred.
• Experience with professional, institutional, inpatient, outpatient, and delegated claims processing.
• Strong knowledge of CMS regulations, provider contracting, reimbursement methodologies, and claims operations.

Responsabilidades

• Review and adjudicate complex medical claims in accordance with plan benefits and CMS guidelines.
• Analyze claim documentation, medical records, authorizations, COB, and eligibility to determine disposition.
• Process adjustments, reopenings, corrected claims, appeals, and PDR cases within regulatory timelines.
• Investigate payment discrepancies, duplicate payments, overpayments, and underpayments.
• Review provider contracts, fee schedules, DRG, APC, ASC methodologies to validate payments.
• Document claim decisions in the claims system.
• Support training and mentoring of Examiners and assist with audits.
• Participate in audits and special projects.

Conhecimentos

Claims adjudication

Medicare claims

CMS regulations

Provider disputes

Excel/Office

Formação académica

High School Diploma or GED

Associate degree

Bachelor's degree

Ferramentas

Microsoft Excel

Outlook

Word

Claims management systems

Descrição da oferta de emprego

Verda Healthcare, Inc. in Huntington Beach, CA is seeking a Senior Claims Examiner to review, analyze, and adjudicate complex claims across professional, institutional, inpatient, outpatient, and Medicare Advantage lines.

The role requires expertise in CMS regulations, provider contracts, and reimbursement methodologies, with a focus on accuracy, quality, and timely processing. The ideal candidate will have 5+ years of healthcare claims processing experience, strong communication skills, and