Senior Stop-Loss Claims Examiner & Coordinator

Community Medical Centers; Fresno (CA); On-site; USD 41,000 - 55,000; Full time

Benefits offered by this job

Free continuing education

Tuition reimbursement

Day-1 vacation

403(b) plan

Free parking

EV charging

Job summary

Community Medical Centers seeks a Senior Claims Examiner and Stop Loss Coordinator to review complex professional and hospital claims for in-network and out-of-network providers. You will verify pricing, confirm prior authorizations, and process payments while tracking stop loss members and filing timelines with the carrier.

Ideal candidates bring 4+ years in medical claims processing, experience with claims systems, and knowledge of CMS guidelines as they relate to stop loss policy compliance.

Qualifications

• 4 years of medical claims processing/adjudication experience required.
• Experience working with claims system/applications and troubleshooting.
• TriZetto/QNXT system knowledge preferred.

Responsibilities

• Review and process complex professional and hospital claims for in-network and out-of-network providers.
• Verify pricing, confirm prior authorization, and process payments.
• Track stop loss members and timely filing of all stop loss claims with the carrier.
• Train staff on claims system enhancements.

Education

High School Diploma, HSE or CHS IEP Certificate

Associate's Degree preferred

Tools

TriZetto/QNXT

Job description

Community Medical Centers seeks a Senior Claims Examiner and Stop Loss Coordinator to review complex professional and hospital claims for in-network and out-of-network providers. You will verify pricing, confirm prior authorizations, and process payments while tracking stop loss members and filing timelines with the carrier.

Ideal candidates bring 4+ years in medical claims processing, experience with claims systems, and knowledge of CMS guidelines as they relate to stop loss policy compliance.