Purpose Statement / Position Summary

The Claims Examiner I accurately review, researches and analyzes professional claims.  Makes benefit determinations and calculations of type and level of benefit based on established criteria and provider contracts.

Essential Functions and Responsibilities of the Job  

• Meet production standard set by department
               
• Consistently meet 95% processing accuracy in paid and denied claims.
               
• Ability to be at work and be on time
               
• Perform other duties as assigned by Management
               
• Be at work and be on time
               
• Follow company policies, procedures and directive
               
• Interact in a positive and constructive manner
               
• Prioritize and multitask

Essential Job Outcomes

• Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines.
               
• Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial, Medicare, and Medi-Cal claims.
               
• Process HCFA 1500’s, UB 92’s and COB claims.
               
• Reviews, processes and adjudicate claims for payment accuracy or denial of payment according to Department’s policy and procedures
               
• Process all claims accurately conforming to quality and production standards and specifications in a timely manner.
               
• Documents resolution of claims to support claim payment and/or decisions appropriately.
               
• Makes benefit determinations and calculations of type and level of benefits based on established criteria and provider contracts. 
               
• Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.
               
• Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines.
               
• Adjudication of Commercial, Medicare, and Medi-Cal claims.
               
• Ability to prioritize, multitask and manage claims assignment within department goals and regulatory compliance and with minimal supervision.
               
• Ability to make phone calls to Provider/Billing offices when necessary based on department guidelines.
               
• Requests additional information or follow up with provider for incomplete or unclean claims.
               
• Ability to effectively communicate with External and Internal teams to resolve claims issues.
               
• Ability to interact in a positive and constructive manner.