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
2 Years of medical claims experience
3 Years of Experience
On Call Staffing Solutions, Inc. is an Equal Opportunity Employer – Minority/Female/Disability/Veterans