Claims Examiner III, PDR Lead- Bakersfield 1.1

Description

Location:

Bakersfield, CA 93309 (Onsite)

Classification:

Full-Time (Non-Exempt)

Benefits:

· Medical

· Dental

· Vision

· Simple IRA Plan

· Employer Paid Life Insurance

· Employee Assistance Program

Compensation:

The initial pay range for this position upon employment commencement is expected to be between $45,864.00 and $57,304.00 annually, translating to $22.05 to $27.55 per hour. However, the base pay offered may be adjusted based on individualized factors, including the candidate's education, certifications, skills, and experience. We value exceptional talent and strive to provide competitive compensation packages tailored to attract and retain top candidates like yourself.

Position Summary:

As the Claims Examiner lll PDR Lead, your primary responsibility will be to Adjudicate medical claims within claims transaction system. Verifying information is accurately captured and complete in databases. You will process both professional (CMS 1500) and institutional (CMS 1450/UB04). During this verification process, the system will prompt you to conduct audits on specific fields to ensure accuracy and completeness for each claim in the batch.

Requirements

Job Duties and Responsibilities:

• Follow written criteria, policies, and procedures to thoroughly review and process claim.

• Evaluate claims for appropriateness of payment, considering factors such as eligibility, benefits, authorizations, coding, compliance, contracted payment terms, or relevant fee schedule, and health plan contracts.

• Stay informed about annual changes in contracts and apply the correct terms to claims, ensuring adherence to contracted payment terms and health plan agreements.

• Ensure accurate and proper denial processing in the system for claims deemed inappropriate for payment, facilitating correct letter generation.

• Consistently meet internal, external, and governmental timeliness standards in processing claims to ensure prompt and efficient service delivery.

• Exercise the freedom to make decisions regarding payment or denial of medical services, handling sensitive and confidential information with utmost discretion.

• Refer claims and accompanying documentation to the Utilization Management (UM) department if they do not align with department policy guidelines

• Interact with various stakeholders, including Eligibility, Member Services, UM, providers, Health Plans, and applicable staff, as needed for claim resolution.

• Maintain compliance with established production and quality standards, ensuring accuracy and efficiency in claim processing.

• Work independently on assigned tasks and activities based on established policies and procedures, demonstrating autonomy and accountability.

• Collaborates with the Claims Operations leadership/management towards the accurate and timely resolution of project issues and is responsible to communicate final resolution to the providers, sales, etc. and/or other business units and/or managers, as needed and/or required.

• Assists with policy and procedure interpretation, development, and training.

• Participates in process improvement activities working to report root causes and corrective actions as needed.

• Researches, analyzes, and resolves complex problems dealing with claims development and finalization.

• Assists with complex claim issues and acts as the primary contact for refunds from providers.

• Manages projects in conjunction with key stakeholders, departments and/or divisions to ensure thorough research, analysis, and resolution within limits of authority. Responds directly to the providers with final resolution of the issues, up to and including root cause documentation/feedback, necessary corrective action plans and/or process improvement initiatives.

• Other related duties as assigned.

Qualifications:

• High School diploma or equivalent.

• Strong knowledge of fee schedule and pricing methodologies for outpatient/inpatient institutional, ancillary, and professional claims.

• Excellent oral and written communication skills to communicate with professionals and outside agencies.

• Demonstrate a strong knowledge of professional and instructional claim processing procedures, with a focus on COB (Coordination of Benefits), TPL (Third Party Liability), and WC (Workers’ Compensation).

• Familiarity with CPT, HCPCS, ICD-10, ASA, Revenue Codes, etc.

• Execute high-volume data entry tasks.

• Apply a robust background in system automation of claims processes and workflows to streamline and enhance operational efficiency.

• Utilize a