Claims Examiner I

Overview

To review, research, and resolve claims for all Medi-Cal claim types within establishedproduction and quality standards, including manual processing. Creates appropriatedocumentation that reflects the actions taken and status of the claim. Generates providercommunication, such as letters. Routes and tracks claims requiring review by other staff anddepartments, and processes when possible.

Responsibilities

Essential Duties and Responsibilities

▪ Reviews, researches, and resolves pended claims for Medi-Cal types: medical, ancillary,long term care, encounter data, other coverage, and batch claims within establishedproduction and quality standards. Completes claims from the Batch Error Report andBatch Pass Report.▪ Routes claims to appropriate Partnership departments and internal staff for additional review.Follows up and completes claims once response to request has been received.▪ Follows established Partnership policies and procedures, Partnership Claims Operating InstructionMemorandums, State of California Medi-Cal Provider Manual guidelines, Title 22regulations, and CMS guidelines when resolving pended claims.▪ Generates claims correspondence as needed.▪ Records daily production statistics and related activities on appropriate reports. Turns inall logs and reports to the Medi-Cal Claims Supervisor.▪ Reviews all work audits in a timely manner and submits any adjustments and correctionswithin the allotted time frame.▪ Supports Claims Department’s needs for resolving all assigned pended claim types.▪ Participates in special projects and assignments as required.▪ Other duties as assigned.

Qualifications

Education and Experience

High school diploma or equivalent; prior experience in claimsprocessing, medical billing, or other related healthcare administrativefunctions preferred.

Special Skills, Licenses and Certifications

Knowledge of CPT and ICD-10 diagnosis coding preferred.

Performance Based Competencies

Effective written and oral communication skills. Good organizationskills. Ability to exercise good judgement within scope of authority andhandle sensitive issues with tact and diplomacy. Ability to stay focusedon repetitive work and meet production and quality standards. Abilityto accurately complete tasks within established timelines. Consistentlymeet production standards without compromising quality on all tasks.

Work Environment And Physical Demands

Ability to use a computer keyboard. More than 80% of work time isspent in front of a computer monitor. When required, ability to move,carry, or lift objects of varying size, weighing up to 5 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$29.95 - $35.19

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.