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Medical Claims Processor

Company: Aston Carter
Location: Alhambra
Posted on: January 15, 2022

Job Description:

This position is responsible for analyzing and validating claim data elements and claims processing. The incumbent is responsible for adhering to the regulator and internal processing guidelines in conjunction with the Net Work Medical Management policies and procedures related to claims adjudication. Highly knowledge understanding of EZ-CAP relative to claims payments. Your efforts will support the accurate & timely payment of claims. Tasks for the position will include testing new releases, making enhancement recommendations, and evaluating contracts for configuration.


-Performs through review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services.
-Processes non-institutional claim types for all line of business (Medicare, Medical, Commercial, -.etc).
-The Specialist should clearly understand the products and healthcare benefits services offered to customers, including cost share, limits and regulatory rules and guidelines.
-Configure provider contracts, Fee schedule updates and other documents.
-Develop configuration testing & validate accuracy of data loaded
-Communicated required system updates to Provider Contracting & Claims operations.
-Coordinate research & resolution of debarred & sanctioned providers.
-Corrects system generated errors manually prior to final claims adjudication.
-Communicated required system updates to Provider Contracting & Claims operations.
-Process claims based upon the provider 's contract/agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and NMM policies and procedures.
-Analyzes and validates Medi-cal pricing researches, Adjusts and adjudicates claims reviews services for accurate charges and utilizes current billing code sets, (i.e International Classification Diseases (ICD 10) Codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference.
-Validates eligibility and other possible health insurance coverage on the claims (i.e Medicare primary, California Children services (CCS),,)
-Alerts manager or supervisor of more complex issues that arise.
-Processes claim exception reports as assigned
-Other duties as assigned by management
-Recognize claim correspondences from multiple IPAs.
-Recognize the health plan financial risk (Division of Financial Responsibility)
-Recognize the difference between Shared Risk and Full Risk claims.
-Maintain required levels of production and quality standards as established by management.
-Attendance at employer worksite is an essential job requirement.
-Work assigned claim project to completion
-Contribute to team effort by accomplishing related results as needed.
cpt coding, icd-10, medical terminology, claims processing, claims adjudication
Top Skills Details:
cpt coding,icd-10,medical terminology,claims processing,claims adjudication
Additional Skills & Qualifications:
-Knowledge of MS Word, Excel and basic medical terminology is required.
-Typing speed 70+ WPM and knowledge of 10 key desired.
-Ability to multi-task and meet deadlines.
-Strong organization skills; ability to multitask and properly manage time
-Position may require unscheduled overtime, week-end work
-Ability to understand work with proprietary software applications.
-Organizational ability and ability to exercise good judgment.
-Work independently as part of a team.
-At least 2 year plus of claims processing experience in the health insurance industry or medical health care delivery system.

High School graduate or equivalent required.

EZ-CAP knowledge; or equivalent combination of education and experience.

Excellent knowledge of CPT, HCPCS, ICD-10 CM, ICD-10 PCS, etc.
Experience Level:
Entry Level

About Aston Carter:

At Aston Carter, we 're dedicated to expanding career opportunities for the skilled professionals who power our business. Our success is driven by the talented, motivated people who join our team across a range of positions - from recruiting, sales and delivery to corporate roles. As part of our team, employees have the opportunity for long-term career success, where hard work is rewarded and the potential for growth is limitless.
Established in 1997, Aston Carter is a leading staffing and consulting firm, providing high-caliber talent and premium services to more than 7,000 companies across North America. Spanning four continents and more than 200 offices, we extend our clients ' capabilities by seeking solvers and delivering solutions to address today 's workforce challenges. For organizations looking for innovative solutions shaped by critical-thinking professionals, visit Aston Carter is a company within Allegis Group, a global leader in talent solutions.
The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please call 888-237-6835 or email for other accommodation options. However, if you have questions about this position, please contact the Recruiter located at the bottom of the job posting. The Recruiter is the sole point of contact for questions about this position.

Keywords: Aston Carter, Alhambra , Medical Claims Processor, Healthcare , Alhambra, California

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