BAKERSFIELD, CA
About the role
Under management direction, responsible for reviewing and processing all types of medical and facility claims from contracting and non-contracting providers and from subscribers and enrollees for payment in an accurate and timely manner. Responsible for applying correct contract benefits, policies and procedures.
This position is responsible for claims auditing and payment functions for a Knox-Keene licensed health maintenance organization (HMO).
Essential Duties and Responsibilities
Resolve system suspended claims for:
* PCPs
* Labs
* Radiology
* Less complicated specialists
* Physical Therapy
•Deny inappropriate claims following policy guidelines.
• Prepare claims that must be routed to other departments for further review.
• Review difficult claims with guidance from Claims Supervisor.
• Responsible for identifying billing errors and possible fraudulent claims submissions.
• Obtain eligibility verification and other health insurance coverage by Internet or POS.
• Responsible for correct manual calculation of benefits when applicable.
• Responsible for identifying possible CCS eligible claims for further investigation.
• Report overpayment refund requests on SharePoint log
• Maintain productivity and quality in accordance with established guideline.
• Perform other job-related duties as required.
• Regular Predictable attendance.
• Adheres to all company policies and procedures relative to employment and job responsibilities.
Employment Standards:
* High School Diploma from an accredited school or equivalent.
* Minimum of one (1) year medical Claims Examiner processing experience.
* Individual must have good organizational skills and the ability to make good decisions.
* Knowledge of: Computerized on-line data entry systems; organizational structure of medical claims processing; medical terminology; HCPCS, CPT & ICD-10 coding, UB04 and CMS1500 forms.
* Ability to: Adapt to a rapidly evolving work environment; work independently; communicate with a variety of personnel and providers.
DISCLAIMER:
The listed position purpose, job duties, responsibilities, competencies, skills, essential functions, education factors are the minimum purposes, duties, responsibilities, competencies, skills, essential functions, and education factors for the position. The requirements and conditions listed in this job description are not exclusive of the tasks that an employee may be required to perform. Company reserves the right to revise this job description at any time, and to require employees to perform other tasks as circumstances or condition of its business considerations or work environment change.
Qualifications
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