Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.
Supports the overall 100% quality effectiveness to ensure that all claims are processed accurately and complete to insure appropriate adjustment code usage, and payment rate.
Duties and Responsibilities
- Proficient with Federal and State requirements in claims processing.
- Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations.
- Proficient in rate application for all CMS 1500 claims for all lines of business. (Medicare, Commercial, Medi-Cal, & Healthy Families).
- Proficient in rate application for all outpatient & inpatient facility, ASC, Interim rate and CMAC rates of payment methods to applicable lines of business. (Medicare, Commercial, Medi-Cal, and Healthy Families).
- Must be able to verify that claims are paid in accordance with correct contractual provision regulatory guidelines and all company and departmental policies and procedures.
- Must be able to work independently and successfully with limited supervision.
- Must be able to work with Claims Examiners, give direction and answer claims related questions to improve overall quality of the department, and individual examiners.
- Performs “pre” and “post” audits for all department examiners, at all levels.
- Ability to take verbal as well as written direction from Claims Operation Supervisor.
- Can effectively use “Crystal reports” to capture deficiencies in processed claims prior to check run.
- Run valid reports and provide monthly reporting to Claims Operations Supervisor of claims examiner’s quality.
- Must keep individual Claims Examiner results at a confidential level between Auditor, Claims Examiner, and Claims Operation Supervisor. Results are not discussed with other examiners.
- Makes recommendations to improve audit procedures and consistency throughout the team.
- Familiarize and comply with claims timeliness guidelines: Commercial claims 45 working days; Medi-Cal claims 30 calendar days; Medicare non-contracted claims 30 calendar days; Medicare contracted claims 60 calendar days.
- Proficient in, the application of “Coordination of Benefits”.
- Proficient in, and knows how to use and apply Health Plan Benefit Matrices and Division of Financial Responsibility.
- Complies with all Company and Department Policies and Procedures.
- Assist and resolve any grievances that the Claims Call Center needs assistance on.
- Prompt and accurate response to claims related questions from Supervisors, and Mgmt.
- Identify claims that fall under Third Party Liability (TPL).
- Identify claims that are potential Stop Loss Case.
- Must have three years of claims processing and or auditing experience.
- Internal/external audit experience is preferred
- Must have the ability to work effectively with minimal supervision.
- Proficient in medical terminology, CPT, ICD9, Revenue codes, HCPCS codes
- Excellent verbal and written communication skills.
- Excellent organizational skills and interpersonal skills.
- Experience with EZ-CAP system claims module.
We’re Making Healthcare Right. Together.
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.