The position analyzes and processes claims; responsible for following regulatory and internal guidelines in conjunction with CalOptima policies and procedures as they apply to claims adjudication. Senior level is responsible to adjudicate more complex claims, requiring additional research or problem solving.
Responsible for accurate and timely adjudication of claims according to guidelines.
Analyzes, processes, researches, adjusts and adjudicates claims with the use of accurate procedure/revenue, ICD-9 and ICD-10 codes, under the correct provider and member benefits, i.e. co-payments, deductibles, etc.
Claims processing based upon contractual and/or CalOptima agreements, involving the use of established payment methodologies, Division of Financial Responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures.
Alerts manager or supervisor of issues that impact production and quality, i.e. incorrect database configurations, non-compliant claims, etc.
Responds to incoming calls from providers of service in a timely and courteous manner.
Resolves issues as presented or as referred by the examiners.
Processes claims based on compliance regulation and timeframes.
Process both professional (CMS-1500) and facility (UB-04) claim types.
Maintain quality and productivity standards as set by management.
Resolve provider or physician group (network) claims inquiries.
Responds to questions from examiners. Explains processing guidelines and internal processes when needed.
Review services for appropriateness of charges and apply authorization guidelines during claims processing.
Prepares written requests to providers; follows up and handles completion of claim for returned correspondence.
Other duties and projects as assigned by management.
Meet and maintain established quality and production standards.
Work independently and as part of a team.
Develop and maintain effective working relationships with all levels of staff and providers.
Handle multiple tasks and meet deadlines.
Effectively utilize computer and appropriate software and interact as needed with CalOptima Claims Processing Systems.
Experience & Education:
High School graduate or equivalent required.
3+ years experience processing on-line claims in a managed care and/or PPO/indemnity environment required.
Experience processing Medicare or Medi-Cal claims preferred.
Must have good customer service skills required.
Revenue Codes, CPT-4/HCPCS, ICD-9 and ICD-10 codes.
Industry pricing methodologies, such as RBRVS, Medicare/Medi-Cal Fee Schedule, etc.
Benefit interpretation and administration.
Medicare/Medi-Cal guidelines and regulations.
Job Location Orange, California, United StatesPosition TypeFull-Time/Regular