$16-17hr, HMO Medical Claims Examiner needed for hospital in Anaheim!!! – Anaheim

Well known hospital organization in Anaheim has an immediate need for a MEDICAL CLAIMS EXAMINER with HMO processing experience. Hours are from 8 - 4:30.

Job Summary:

Working under the direction of the Claims Director, this position is responsible for consistently and accurately adjudicating all complex contracted professional capitated claims with fee-for-service carve outs, professional and hospital claims for non-contracted provider and contracted hospital claims for both Commercial and Senior plans within the timeliness and accuracy standards set forth by CMS, Department of Managed Care, AB1455 and the Claims Department polices and procedures.

Essential Functions:

Reviews and processes all contracted capitated claims and fee-for-service PCP administration fee for-service claims paid and or denied while achieving and maintaining a 95% accuracy rate. 25%

Reviews and processes claims acknowledgment, payment and denial as set forth by CMS, Healthplans and departmental policy and procedures while achieving and maintaining a 95% timeliness standards.
25%

Achieving and maintain 95% production requirements per claim type utilizing departmental policy and procedures as established per Healthplan and Network. 20%

Recognizes inappropriate CPT, ICD-9, HCPCS, and Revenue codes and accurately research member eligibility, duplicate claims submissions, out of network services, out of area services and COB and adjudicate according to departmental procedures. 15%

Monitors and updates inventory reports in order to track claims in inventory and follows-up on all claims suspended for review purposes or additional information requests until claims are in a final status.
10%

Alerts Claims Management of all claims issues that would impact any Healthplan compliance. 5%

Experience:
4 years of experience prior experience as a Claims Examiner in an IPA, Medical Group or Health Plan.
Familiarity with computerized claims processing/transaction system

Please contact Angela at AppleOne/Orange for immediate consideration!

Apply Here
Salary: 25000 - 35000