Claims Examiner

Essential Job Duties

• Examine, review and process claims according to contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
• Assess appropriateness of returned, denied, or paid claims by reviewing and following contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
• Ensure claim timeliness processing standards are being met
• Work alongside manager to establish and maintain claims processing rules that meet all regulatory and business requirements
• Assist internal and external partners with questions related to claims decisions or claims statuses
• Maintain a comprehensive understanding of claim processing guidelines at both the federal and state level

Job Requirements

• High School Diploma or Equivalency, professional experience may be substituted
• Minimum of three (3) years of experience with processing, researching, and adjudicating claims in a complex managed care environment
• Working knowledge of the health plan insurance industry and CPT/HCPCS procedure codes, and relevant federal and state regulations
• Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee schedule, Diagnosis Related Groups (DRG), Multiple Procedure Payment Reduction (MPPR) and benefit interpretation and administration
• In depth experience with Medicare and Medicaid claims processing
• Demonstrated skills within Microsoft Office Applications & electronic claims processing systems
• Strong organizational, analytical, communication, and time management skills

Benefits of Working at WelbeHealth

• Medical insurance coverage (Medical, Dental, Vision)
• Work/life balance – we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, sick time
• Advancement opportunities - We’ve got a track record of hiring and promoting from within, meaning you can create your own path!
• And additional benefits