MEDI-CAL CLAIMS EXAMINER

Position summary:

Reports to the supervisor of claims. Individual must be organized and utilize time efficiently. Responsible for claims adjudication and preparation for payment. Responsible to make determination regarding payment status, denial status and limited contract interpretation. Any other assigned duties as deemed necessary and directed by supervisors or the claims manager.

Functions:

  • Experienced claims examiner to process inpatient and outpatient hospital claims "Ub-04" and physician claims "Hcfa 1500"

  • Claims adjudication, coding and claims coverage determination.

  • Knowledge of medicare, medi-cal, and commercial.

  • Ezcap experience

  • Interpreting provider contracts and contract rates for medicare, medi-cal and commercial

  • Processing and adjudicating refunds and reimbursements appeals and grievances.

  • Verifying eligibility, checking effective dates of primary insurance cob. Etc.

  • Maintain amm claims department quota

  • Process and adjudicate rx prescription claims.

  • Ab1324 knowledge

  • Letter development knowledge

  • Guidelines for processing a 30, 60 and denied claims

Job requirements:

Two to three years experience in processing claims. Individual should also demonstrate the ability to work with all levels of staff within amm. Must be highly organized and able to perform multiple tasks efficiently, be computer literate and must be knowledgeable in medical terminology. Must have knowledge of cpt codes and icd9 codes. Keyboard skills of 60 wpm is desired. Must have experience in processing all lines of business medicare, medi-cal, and commercial claims. Proficient in rbrvs , hcpcs, and cpt coding practices. Ability to work in a fast-paced environment. Knowledge of software applications such as microsoft products.