Title: Claims Examiner II
Location: Fountain Valley
Department: Claims
Status: Full-Time
Shift: Days (8hrs) Predominantly Remote
Pay Range: $22.41/hr - $32.50/hr
MemorialCare is a nonprofit integrated health system that includes four leading hospitals and over 200 sites of care throughout Orange and Los Angeles Counties. We are committed to increasing access to patient-centric, affordable, and high-quality healthcare; your contributions are integral to our recognition as a market leader in value-based care models.
Across our family of medical centers, we support our talented employees in reaching the highest levels of professional development, contribution, collaboration, and accountability. We are dedicated to helping you achieve your full potential in an environment of respect, innovation, and teamwork.
Position Summary
The Claims Examiner II accurately reviews, researches, and analyzes professional, ancillary, and institutional inpatient and outpatient claims.
Essential Functions and Responsibilities of the Job
- Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines.
- Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims.
- Comprehensive knowledge of various fee schedules and CMS prices for outpatient/inpatient institutional, ancillary, and professional claims.
- Ability to identify and report processing inaccuracies related to system configuration.
- Process all types of claims, including HCFA 1500, outpatient/inpatient UB92, high dollar claims, COB, and DRG claims.
- Reviews, processes, and adjudicates claims for payment accuracy or denial of payment according to Department’s policy and procedures.
- Processes all claims accurately conforming to quality and production standards in a timely manner.
- Documents resolution of claims to support claim payment and/or decision.
- Makes benefit determinations and calculations of type and level of benefits based on established criteria and provider contracts.
- Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.
- Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines.
- Adjudication of Commercial and Medicare Advantage claims.
- Ability to prioritize, multitask, and manage claims assignment within department goals and regulatory compliance.
- Ability to make phone calls to Provider/Billing offices when necessary, based on department guidelines.
- Requests additional information or follows up with provider for incomplete or unclean claims.
- Ability to effectively communicate with External and Internal teams to resolve claims issues.
- Ability to interact in a positive and constructive manner.
Experience
- Minimum of 5+ years’ experience in processing all types of professional, ancillary, and institutional claims in Managed Care.
- Comprehensive knowledge of various fee schedules and CMS prices for professional, facility, and ancillary claims.
- Comprehensive knowledge of CPT, ICD-9, and ICD-10 codes, inpatient procedure coding, HCPCS, Revenue Codes, medical terminology, and COB required.
- Working knowledge of Claims Information systems.
- Understands division of financial responsibility for determination of financial risk.
- Type a minimum of 45 words per minute.
Education
High School diploma
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