Medical Claims Examiner

Orange, CA | Temporary

Job ID: [SA] Medical Claims Examiner Industry: Healthcare Pay Rate: $22.00

We are looking for an experienced Medical Claims Examiner with excellent analyzing skills. YOU will be accountable for following regulatory and internal guidelines in conjunction with policies and procedures. YOU will also adjudicate more complex claims, requiring additional research or problem solving.

 Position Responsibilities

  • Responsible for accurate and timely adjudication of claims according to guidelines.
  • Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e. co-payments, deductibles, etc.
  • Claims processing based upon contractual and/or agreements, involving the use of established payment methodologies, Division of Financial Responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures.
  • Responds to incoming calls from providers of service in a timely and courteous manner.
  • Process both professional (CMS-1500) and facility (UB-04) claim types.
  • Maintain quality and productivity standards as set by management.
  • Resolve provider or physician group (network) claims inquiries and apply resolution in a timely fashion.
  • Responds to questions from examiners. Explains processing guidelines and internal processes when needed.
  • Review services for appropriateness of charges and apply authorization guidelines during claims processing.
  • Prepare written requests to providers; follow up and handle completion of claim for returned correspondence.

Medical Claims & Adjudication is a requirement for this position

Ability to commit to three (3) month minimum and willing to extend as needed- potentially to six (6) month or more

High School graduate or equivalent.

2-3 years experience processing on-line claims in a managed care and/or PPO/indemnity environment.

Experience processing Medicare or Medi-Cal claims

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