Are you driven by a desire for precision and have a profound impact on the healthcare sector? We are looking for a Claims Examiner III to join our dynamic remote team. In this role, you'll ensure the meticulous processing and resolution of healthcare claims, thereby directly improving the service our members receive.
Responsibilities:
Advanced Claims Processing: Apply your in-depth knowledge of medical terminology, coding, and healthcare claim procedures to review and adjudicate complex claims.
Quality Assurance: Conduct detailed assessments of claims to ensure they meet all regulatory guidelines and our high internal standards. Identify and correct discrepancies or errors, and take action against potential fraud.
Claims Resolution: Handle complex inquiries, appeals, and disputes from providers and members. Work collaboratively with internal and external groups to collect required information and resolve issues efficiently.
Billing and Coding Analysis: Evaluate current coding and billing practices to pinpoint trends and areas needing enhancement. Provide constructive feedback to refine billing processes and reduce errors.
Documentation and Reporting: Maintain meticulous records of all claims processing activities and decisions. Produce regular reports to monitor performance and facilitate ongoing improvement.
Stellar Customer Service: Offer outstanding service by promptly responding to queries and resolving issues, ensuring clear and effective communication with all stakeholders.
Qualifications:
A Bachelor's degree in Healthcare Administration, Business, or a related field is preferred.
At least 10 years of experience in HMO claims processing within a managed care environment, with a strong track record in handling complex claims.
Deep knowledge of specific healthcare regulations (AB1324, AB1455) and familiarity with various payment methods (Outpatient PPS, Inpatient DRG, etc.) across multiple lines of business such as Medicare, Commercial, Medi-Cal.
Expertise in healthcare billing codes, medical terminology, and claim software tools.
Exceptional analytical skills and attention to detail.
Strong communication skills, capable of effective interaction with colleagues and external partners.
Proficiency in Microsoft Office and other industry-related software applications.
Why You Should Apply:
Meaningful Impact: Play a crucial role in the health and wellbeing of our members while ensuring the integrity of healthcare processes.
Career Development: Gain access to a variety of training and development opportunities that foster skill enhancement and professional growth.
Supportive Team Environment: Thrive in a culture that prizes teamwork, respect, and recognition of individual contributions.
Comprehensive Benefits Package: Benefit from a competitive range of benefits, including health, dental, and vision insurance; life insurance; a 401(k) with matching; flexible spending accounts; and generous paid time off.
Join Us:
If you're eager to advance your career in a role where you can make a significant difference, we encourage you to apply for the Healthcare Claims Examiner III position today!
Application Note:
For alternative application methods or if you require special accommodations during the application process, please directly contact our HR team.
Employment Type: Full-Time
Salary: $ 22.00 30.00 Per Hour
