Claims Examiner
W
WelbeHealthSenior care
Remote, CA, USAFull-TimeMiddle
Salary55,930.55 - 73,828.33 USD per year
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Job Details
- Experience
- Minimum of three (3) years of experience
- Required Skills
- Microsoft Office
Requirements
- High School Diploma or Equivalency, professional experience may be substituted
- Minimum of three (3) years of experience with processing, researching, and adjudicating claims in a complex managed care environment
- Working knowledge of the health plan insurance industry and CPT/HCPCS procedure codes, and relevant federal and state regulations
- Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee schedule, Diagnosis Related Groups (DRG), Multiple Procedure Payment Reduction (MPPR) and benefit interpretation and administration
- In depth experience with Medicare and Medicaid claims processing
- Demonstrated skills within Microsoft Office Applications & electronic claims processing systems
- Strong organizational, analytical, communication, and time management skills
Responsibilities
- Examine, review and process claims according to contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
- Assess appropriateness of returned, denied, or paid claims by reviewing and following contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
- Ensure claim timeliness processing standards are being met
- Work alongside manager to establish and maintain claims processing rules that meet all regulatory and business requirements
- Assist internal and external partners with questions related to claims decisions or claims statuses
- Maintain a comprehensive understanding of claim processing guidelines at both the federal and state level
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