Petaluma, CA Remote Full Time
Position Summary:
The Claims Examiner is responsible for processing, examining, and adjudicating medical claims for payment or denial in a manner that maintains compliance within respect to Commercial, Medicare
Advantage and Medi-Cal regulatory requirements while achieving claims service level objectives. This position is responsible for the accurate and timely processing of all claims upon first receipt. Claims Examiner
Essential Job Functions:
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- Reviews and or enters claims data into system while interpreting coding and understanding medical terminology in relation to diagnosis and procedures.
- Review, analyze, and resolve claims through the utilization of available resources for moderately complex claims. Claims Examiner
- Examines claims to determine if further investigation is needed from Sr. Claim Examiner or other departments and routes claims appropriately through the system.
- Adjudication of claims to achieve quality and production standards applicable to this position.
- Maintain procedural accuracy of 97%, and financial accuracy of 97%.
- Ensure legal compliance by following company policies, procedures, guidelines, as well as federal insurance regulations.
- Respond timely to all Customer Service, Provider Relations type questions. Claims Examiner
- Collaborate with and maintain open communication with all departments within Meritage Medical Network to ensure effective and efficient workflow and facilitate completion of tasks/goals.
- Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and seeks to influence these behaviors in others.
- Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.
- Models professional work standards and behaviors to maintain and strengthen a professional working atmosphere and strictest confidentiality within the department and with other Meritage internal and external customers and work partners.
- Is accountable for work performed by self, works to develop and maintain trusting working relationships with others, and seeks to continuously learn from errors and experiences, as well as new developments in job specific Call Center administration and operational areas. Claims Examiner
- Adopts, incorporates, is mindful of, and otherwise supports Meritage’s overarching annual and longer-term strategic business goals and objectives while performing work duties, special projects and other duties as assigned within or outside of the Call Center.
- Performs other than normally assigned duties and projects, as directed, and required, within and outside of the Claims department to support Meritage’s overall business needs, goals, and objectives. Claims Examiner
Requirements & Qualifications:
- High School diploma (or General Education Diploma “GED”) required.
- Minimum of 2 years’ experience processing or billing primary and specialty provider claims.
- Knowledge of DMHC, DHCS and CMS regulations.
- Comprehensive knowledge of CPT and ICD-10 codes.
- Must have excellent problem-solving skills.
- Excellent interpersonal written and verbal communications skills.
- Strong attention to detail.
- Enjoys working as part of a team. Claims Examiner
- Multi-task and keyboard while researching, following up, resolving, and documenting telephonic inquires.
- Microsoft Office Suite applications: Word, Excel, PowerPoint, Outlook, Teams, etc.
- Knowledge of claim benefit interpretation/benefit adjudication logic.
- Must be proficient in problem solving and detecting trends.
- Excellent communication skills – meaning you can adapt to new and different situations, read the behavior of others, have difficult conversations with ease and defuse and resolve conflict.
- Must be able to read and interpret all types of authorization, medical claim forms and member benefit plans.
- Integrity to follow HIPAA guidelines on maintaining patient privacy.
- Ability to adapt and excel in a fast-paced work environment. Claims Examiner
Job Type: Full-time
Pay: $21.83 – $27.16 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
Education:
- High school or equivalent (Required)
Experience:
- Claims: 2 years (Required)
Work Location: Hybrid remote in Petaluma