DEPARTMENT(S): Claims Administration
REPORTS TO: Supervisor, Claims
FLSA STATUS: Non-Exempt
SALARY GRADE: E - $48,000 - $62,000
JOB SUMMARY
This position is responsible for analyzing and validating claims elements and claims processing. The incumbent is responsible for adhering to the regulatory and internal guidelines in conjunction with CalOptima policies and procedures related to claims adjudication. Senior level examiner is responsible to adjudicate complex claims, requiring additional research or problem solving.
POSITION RESPONSIBILITIES:
- Processes both professional and institutional claims types.
- Performs thorough review of pending claims for billing errors and or questionable billing practices that mighty include duplicate billing and unbundling of services.
- Responsible for manually correcting system generated errors prior to final claims adjudication.
- Processes claims based upon CalOptima contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and CalOptima policies and procedures.
- Analyzes, validates Medi-Cal pricing, researches, adjusts, and adjudicates claims, reviews services for accurate charges; utilizing billing code sets and/or authorization guidelines as reference.
- Processes claims based upon contractual and/or CalOptima agreements, involving the use of established payment methodologies, Division of Financial Responsibility.
- Alerts manager or supervisor of more complex issues that arise.
- Processes claim exception reports as assigned.
- Maintains quality and productivity standards as set by management.
- Other projects and duties as assigned.
KNOWLEDGE & ABILITIES:
- Meet and maintain established quality and production standards.
- Work independently and as part of a team.
- Develop and maintain effective working relationships with all levels of staff and providers.
- Handle multiple tasks and meet deadlines.
- Utilize and access computer and appropriate software (e.g., Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.
EXPERIENCE & EDUCATION:
- High School degree or equivalent required.
- 3+ years of experience processing online claims in a managed care environment required.
PREFERRED QUALIFICATIONS:
- Experience processing Medi-Cal and/or Medicare claims preferred.
KNOWLEDGE OF:
- Revenue codes and billing code sets, i.e., Current Procedural Terminology (CPT), Healthcare Common Procedural Coding System, International Classification Diseases-10 (ICD-10) Codes and medical terminology.
- Industry pricing methodologies, such as Resource Based Relative Value Scale, Medi-Cal Fee Schedule, etc.
- Benefit interpretation and administration.
- Medicare/Medi-Cal guidelines and regulations.
EEO Statement: CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
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ADA/Accommodation Statement: If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations with 72-hour notice by contacting Human Resources Disability Management at 657-900-1134.
Required Skills
Required Experience