Claims Examiner

📋 Description

• Examine, review and process claims per contracts and regulations.
• Assess appropriateness of returned, denied, or paid claims per rules.
• Ensure timely processing of claims meets standards.
• Collaborate with manager to establish claims processing rules.
• Assist internal/external partners with questions on claims decisions/statuses.
• Maintain understanding of federal and state claim processing guidelines.

🎯 Requirements

• High School Diploma or Equivalency; experience may substitute
• 3+ years processing, researching, and adjudicating claims in managed care
• Knowledge of health plan industry, CPT/HCPCS codes, and regulations
• Understanding Medicare/Medi-Cal pricing, DRG, MPPR, and benefit interpretation
• In-depth Medicare and Medicaid claims processing experience
• Proficiency in Microsoft Office and electronic claims processing systems

🎁 Benefits

• Medical, dental, vision insurance
• PTO/holidays/sick time for work-life balance
• Advancement opportunities through internal promotions
• Additional benefits and perks