Claims Processor(Examiner) II (Kearney Mesa)
Long Term Temp (> 30 Days)
A large healthcare organization in San Diego seeks a Claims Processor (Examiner) II. The primary purpose of this position is to examine & process claims from the UB04 & CMS-1500 claim forms into the claims adjudication system for all capitated & shared services accounts. This position is responsible for the accurate review, input & adjudication of claims using reasonable payment policies & methodologies that are consistent with & recognized by Health Plans, nationally recognized medical organizations, federal regulatory bodies, & contractual obligations of the organization.
Process claims accurately & efficiently in accordance to payment policies & procedures.
Maintains production standard; general productivity is expected to be per day in accordance with department metric standards.
Reviews all incoming claims to verify eligibility, benefits, & authorization information according to department guidelines.
Makes appropriate edits, changes, & corrections to inloaded claims in the system to ensure accurate & timely payment of claims as defined by leadership.
Specific Essential Function :Generate the appropriate denial letters and/or reports based on established criteria; Reconcile daily, weekly, monthly reports in a timely manner as defined by dept guidelines.
Inload daily/weekly EDI files; generate and/or reconcile EDI reports per department guidelines.
Identify Third Party Liability (TPL) claims & notify/submit to recovery agent for possible recoveries in accordance with department guidelines.
Act as a backup in generating weekly check run & corresponding Explanation of Payments (EOP-s).
H.S. Diploma,GED,or Equivalent
HMO Industry Experience
At least 2 years of medical claims processing experience
3+ years of medical claims processing experience
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.