Claims Examiner I
Summary Description:
The Claims Examiner I is responsible for adjudicating medical claims accurately and in a timely manner to ensure state regulations are met. The Claims Examiner I provides thorough review, analysis, and on-time adjudication of claim payment determinations, ensuring payments are billed at the correct contracted rate.
Representative Duties:
Analyze claims for appropriate payer, based on combination of coding, medical group’s service area, and contract per the Division of Financial Responsibility (DoFR) document.
Make claim payment determinations established by internal policy and regulatory agencies.
Process claims and make payment adjustments as necessary.
Process member reimbursement claims and adhere to timeliness guidelines as established by regulatory agencies.
Consistently maintain the department audit scores.
Forward misdirected claims to appropriate payer within 10 business days of receipt.
Acknowledge Western Health Advantage’s risk claims within 15 business days of receipt.
Finalize commercial claims for payment or denial within 45 business days of receipt.
Finalize Employee Retirement Income Security Act (ERISA) within 30 days of receipt.
Ensure that clean claims are paid within 30 calendar days of receipt.
Ensure that unclean and/or contracted claims are paid or denied within 60 calendar days of receipt
Consistently perform claims related functions within accepted standards of productivity, accuracy, and timeliness.
Process claims daily with financial accuracy, and payment and procedural accuracy.
Perform other duties and special projects as assigned.
Qualifications:
High School Diploma.
1 year experience working with claims adjudication in the health care industry, preferably HMO.
Ability to identify the difference between to International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and Revenue (Rev) Codes.
Experience working with Facets Application Software is a plus.
Intermediate computer skills, including email, routine database, word processing, spreadsheet, graphics, etc.
Must be able to speak, read, write, and understand the primary language(s) used in the workplace.
Salary:
$19.00- $22.00 Hourly
Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.
Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.