Claims Examiner III
About Us
All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick time, and vacation time as well as a 401k plan. Additional employee paid coverage options available.
Job purpose
The Claims Examiner III is responsible for the processing and/or adjusting and the releasing of hospital or medical claims according to established policies and procedures. Must identify procedural and system inefficiencies and work with the appropriate entities to resolve issues. Examiners also perform research, analysis, reporting and special projects as assigned. Examiners must be able to meet production requirements and quality standards. Must be able to successfully perform all the duties of the Claims Examiner II.
Duties and responsibilities
• Participate in claims workflow projects.
• Create and run Crystal /SQL reports for distribution to claims examiners, other department as needed to maintain claims turnaround time compliance.
• Processing claims for all lines of business including complex claims.
• Complies with all Company and Department Policies and Procedures.
• When needed assist in claims audit preparation/activities.
• Responsible for the processing of claims that are either the financial responsibility of the assigned IPA or capitated Hospital.
• Must meet quantitative production standard of 100 - 150 claims per day.
• Must maintain an error accuracy of under 5%.
• Responsible for validating the diagnosis and procedure codes against the authorized services on Inpatient claims.
• Responsible for the resolution of Provider Disputes (PDR’s) and their documentation (code driven) for required Acknowledgement and Resolution Letters to send to providers.
• Responsible for requesting additional information required to adjudicate claims, by correctly coding claims notes to generate Development Letters and or Notifications to providers.
• Responsible for accurately coding claims notes to generate Denial Letters for claims denied as member liability.
• Ability to resolve claims issues on identified processing errors and make recommendations for improvements to avoid error.
• Identify any overpayment/underpayment in a review and or history search. Follow department protocol for reporting and following up.
• Adjusts voids and reopens claims within guidelines to ensure proper adjudication.
• Resolve any grievances and complaints received through Customer Services, responds when needed to portal/email inquiries and initiates steps to assist regarding issues relating to the content or interpretation of benefits, policies and procedures, provider contracts, and adjudication of claims.
• Support the Claims Department as business needs require.
• May have customer/client contact.
• May assist with training of team members. Works without significant guidance.
• Identify claims payment errors and/or system configuration flaws during day-to-day operation, report to department manager to correct/resolve them.
• Able to assist with check run preparation as needed.
• All other duties as assigned.
Qualifications
• Must have experience with EZ-Cap
• 10+ years or more experience in processing HMO claims in a managed care environment.
• Familiar with all regulatory requirements including CMS, DMHC and DHS.
• Proficient with all Federal and state requirements in claim processing.
• Knowledge of medical terminology and coding.
• Proficient in rate application for outpatient PPS & Inpatient DRG facility, ASC, APC, Interim Rate Payment methods to applicable lines of business. (Medicare, Commercial, Medi-Cal).
• Recognize the difference between Shared Risk and Full Risk claims.
• Proficient in and knows how to use and apply Health Plan Benefit Matrix and Division of Financial Responsibility.
• Proficient understanding of AB1324.
• Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations.
• Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe
• Detail oriented and highly organized
• Strong ability to multi-task, project management, and work in a fast-paced environment
• Strong ability in problem-solving
• Ability to self-manage, strong time management skills.
• Ability to work in an extremely confidential environment.
• Strong written and verbal communication skills
Apply Now
Apply Now
All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick time, and vacation time as well as a 401k plan. Additional employee paid coverage options available.
Job purpose
The Claims Examiner III is responsible for the processing and/or adjusting and the releasing of hospital or medical claims according to established policies and procedures. Must identify procedural and system inefficiencies and work with the appropriate entities to resolve issues. Examiners also perform research, analysis, reporting and special projects as assigned. Examiners must be able to meet production requirements and quality standards. Must be able to successfully perform all the duties of the Claims Examiner II.
Duties and responsibilities
• Participate in claims workflow projects.
• Create and run Crystal /SQL reports for distribution to claims examiners, other department as needed to maintain claims turnaround time compliance.
• Processing claims for all lines of business including complex claims.
• Complies with all Company and Department Policies and Procedures.
• When needed assist in claims audit preparation/activities.
• Responsible for the processing of claims that are either the financial responsibility of the assigned IPA or capitated Hospital.
• Must meet quantitative production standard of 100 - 150 claims per day.
• Must maintain an error accuracy of under 5%.
• Responsible for validating the diagnosis and procedure codes against the authorized services on Inpatient claims.
• Responsible for the resolution of Provider Disputes (PDR’s) and their documentation (code driven) for required Acknowledgement and Resolution Letters to send to providers.
• Responsible for requesting additional information required to adjudicate claims, by correctly coding claims notes to generate Development Letters and or Notifications to providers.
• Responsible for accurately coding claims notes to generate Denial Letters for claims denied as member liability.
• Ability to resolve claims issues on identified processing errors and make recommendations for improvements to avoid error.
• Identify any overpayment/underpayment in a review and or history search. Follow department protocol for reporting and following up.
• Adjusts voids and reopens claims within guidelines to ensure proper adjudication.
• Resolve any grievances and complaints received through Customer Services, responds when needed to portal/email inquiries and initiates steps to assist regarding issues relating to the content or interpretation of benefits, policies and procedures, provider contracts, and adjudication of claims.
• Support the Claims Department as business needs require.
• May have customer/client contact.
• May assist with training of team members. Works without significant guidance.
• Identify claims payment errors and/or system configuration flaws during day-to-day operation, report to department manager to correct/resolve them.
• Able to assist with check run preparation as needed.
• All other duties as assigned.
Qualifications
• Must have experience with EZ-Cap
• 10+ years or more experience in processing HMO claims in a managed care environment.
• Familiar with all regulatory requirements including CMS, DMHC and DHS.
• Proficient with all Federal and state requirements in claim processing.
• Knowledge of medical terminology and coding.
• Proficient in rate application for outpatient PPS & Inpatient DRG facility, ASC, APC, Interim Rate Payment methods to applicable lines of business. (Medicare, Commercial, Medi-Cal).
• Recognize the difference between Shared Risk and Full Risk claims.
• Proficient in and knows how to use and apply Health Plan Benefit Matrix and Division of Financial Responsibility.
• Proficient understanding of AB1324.
• Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations.
• Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe
• Detail oriented and highly organized
• Strong ability to multi-task, project management, and work in a fast-paced environment
• Strong ability in problem-solving
• Ability to self-manage, strong time management skills.
• Ability to work in an extremely confidential environment.
• Strong written and verbal communication skills
Apply Now
Apply Now