Medicare Sr. Claims Examiner

Central Coast Salary Range: $25.63/hour - $35.89/hour

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

This position is responsible for: researching, correcting and responding to all D-SNP  pended claims as well the review of Audit reports in a timely manner; determining whether a claim should be paid (in accordance with the policies and procedures) and maintaining correspondence for document procedure /medical/CPT/ HCFA codes; assuring all regulatory guidelines are being followed.

Duties and Responsibilities

• Review, price and release claims associated with the assigned claim types (paper and electronic)

• Review Manual Review reports that suspend for review for D-SNP claims

• Review audit reports for D-SNP claims and calls,

• Analyze current processes and work with Supervisor to automate or improve quality where fit

• Assist with ideas for creation of SCF (System Change Forms) or QNXT equivalent when applicable

• Keep up to date on all D-SNP policies and provide materials for improvement projects within Department

• Assure all regulatory guidelines are being followed and monitored

• Maintain daily activity log

• Assist with the processing of claims

• Audit and report all billing & error trends found during the course of review and data entry

• Maintain processes and timelines required by AB1455 Claims Settlement Practices and DHCS Regulations

• Other duties and projects assigned

Knowledge Skills Abilities

• QNXT experience

• Strong knowledge of the D-SNP program

• Strong knowledge in dual eligible claims processing (Medi-Cal and Medicare D-SNP )

• Prior experience in high volume production environment

• Good oral and written communication skills

• Attention to detail

• Medical terminology and/or coding experience is highly desirable

Education and Experience

Required:

• High school diploma or equivalent

• Five (5) years’ experience as a Claims Examiner