Claims Examiner

DUTIES:
The Claims Examiner is responsible for:

- The accurate and timely processing of all lines of business, including the most complex claims.
- Auditing claims for excessive charges, duplicates, unbundling, and medical upcoding.
- Maintaining department databases used for report production and tracking on-going work.
- Resolving member and provider claims payment disputes.
- Assisting management with in-house and on-site training as offered to employees and providers.
- Negotiating reimbursement amounts for out-of-network claims.

SKILLS:

EDUCATION:

- High School Graduate required.
- AA Degree preferred.

REQUIRED SKILLS/QUALIFICATIONS:

- At least three years of healthcare claims processing experience in a managed care environment.
- Ability to operate PC based software programs or automated database management systems.
- Strong communication skills with excellent analytical and problem-solving skills.
- Ability to self manage in a fast paced environment.
- Extensive knowledge of medical terminology, standard claims forms and physical billing coding, ability to read/interpret contracts, standard reference materials, and complete product and Coordination of Benefits (COB) knowledge.
- Moderate knowledge of Microsoft Work and Excel.

PREFERRED:

- Previous Medi-Cal or Medicare claims processing experience.