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Claims Processor

Date Posted: 2/22/2024

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Job Description

Responsibilities BASIC JOB PURPOSE: Under the supervision of the Claims Manager or designee, claims processors are responsible for accurately and efficiently entering and processing claims/invoices for the organization REPORTS TO: Director of Finance or Designee The Claims Examiner is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes: Processing claims for all lines of business, including complex claims Monitoring itemized billings for excessive charges, duplications, unbundling, and medical coding Determining prior authorization/precertification of services paid via system and/or health services Requesting and reviewing medical records as needed for basic information to validate billing information Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated Meeting and exceeding performance measurements for Claim Examiners as required by department to meet regulatory compliance Determining correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions Processing all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner Documenting provider claims/billing forms to support payments/decisions Identifies dual coverage and potential third-party savings/recovery Maintaining department databases used for report production and tracking on-going work Claims will be processed within the contractual and/or regulatory time frames Perform special projects and ad-hoc reporting as necessary Projects will be complete, and reports will be generated within the specific time frame agreed upon at the time of assignment Working with internal departments to resolve issues preventing claims processing or enhancing processing capabilities May assist in testing, changing, analyzing and reporting of specific enhancements Any other duties as assigned by management

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance.

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Job Snapshot

  • Employee Type:Full-Time
  • Location:Brea, CA
  • Job Type:Admin - Clerical
  • Experience:3-5 years
  • Education:High School
  • Date Posted:2/22/2024
  • Contact: Bertie Mura (714) 988-2843
  • Pay Range: $50,000.00 - $60,000.00 Annually
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Job Reference: JN -022024-359750