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CLAIMS EXAMINER

Company: Network Medical Management Inc
Location: Alhambra
Posted on: January 15, 2022

Job Description:

Job DescriptionThis 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.KEY RESPONSIBILITIES: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 loadedCommunicated 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 assignedOther duties as assigned by managementRecognize 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 completionContribute to team effort by accomplishing related results as needed.QUALIFICATIONS:To perform this job successfully, this individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.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 timePosition may require unscheduled overtime, week-end workAbility 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.EDUCATION and/or EXPERIENCEHigh School graduate or equivalent requires.EZ-CAP knowledge; or equivalent combination of education and experience.Excellent knowledge of CPT, HCPCS, ICD-10 CM, ICD-10 PCS, etc.#HPIND

Keywords: Network Medical Management Inc, Alhambra , CLAIMS EXAMINER, Other , Alhambra, California

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