Claims Examiner III

Position Title: Claims Examiner III
Position Type: Full Time
Location: Huntington Beach, CA and Arcadia, CA

Reports To: Claims Manager

About Clever Care Health Plan

Clever Care Health Plan is a newly founded Medicare Advantage health plan serving Medicare beneficiaries in Southern California. Our employees are passionate in providing best services to our members and healthcare providers. Our three office locations are in Arcadia (Los Angeles County), Huntington Beach (Orange County) and New York City.

Job Summary

Under the direction of the Claims Manager, the Claims Examiner III reviews and adjudicates complex or specialty claims, submitted either via paper or electronically. The Claims Examiner III performs advanced administrative/operational/customer support duties that require independent initiative and judgment. This includes but is not limited to; Inpatient, COB high dollar, dialysis, oncology/chemo, home health agency, SNF, hospital exclusions and claim adjustments in an accurate and expedient manner. The position also includes auditing of professional claims for accuracy using, CCI edits, CMS LCDs, NCDs, and other Plan policies.

Functions and Job Responsibilities

The Claims Examiner III determines whether to return, deny, or pay Institutional claims following organizational policies and procedures.
Conducts end to end claims audits to ensure claims are processed accurately according to benefits assignment, applicable contracts, pricing and configuration rules.
Ensures Institutional claims also meet compliance guidelines.
Performs claims testing on claims configuration and enhancements.
Decisions are typically focused on methods, tactics and processes for completing administrative tasks/projects.
Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
Adjudicates complex professional and institutional claims.
Assist with training and mentoring of new team members.
Assist with the testing of new claim processing procedures or projects.
Responsible for meeting performance measurement standards for productivity and accuracy.
Adjudication of claim adjustments.
Review and correct claims involving data integrity issues.
Interface with other Clever Care Departments, when necessary regarding claims issues.
Participate in Claims Department Team Meetings, and other activities as needed.
Supports all department initiatives in improving overall efficiency.
Identifies and recommends solutions for error issues as it relates to pre-payment of claims.
Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication and recommending solutions to resolve these issues.
Manages a caseload of various types of complex claims. Procures all medical records and statements that support the claim.
Meets department quality and production standards.
Meet State and Federal regulatory Compliance Regulations on turnaround times and claims payment for multiple lines of business
Performs other duties as required.

Education and Experience

Associate’s Degree (Bachelor’s preferred) or equivalent combination of experience in health insurance or related fields, which would provide the necessary knowledge, skills and abilities to successfully perform the work
Two (2) years experience in examining and processing Institutional claims for Inpatient, Dialysis, SNF, Home Health using Medicare pricers.
Two (2) years experience in examining and processing medical claims professional or institutional.
Preferred Experience Medicare/Medi-Cal experience preferred.
Claim adjustments, provider appeals and/or disputes preferred.

Knowledge, Skills, and Abilities

Advanced knowledge and skills in medical terminology, HCPCS/CPT, and ICD-9/ICD-10 required.
Knowledge of Centers for Medicare and Medicaid services claims payment guidelines.
Strong analytical skills, including the ability to analyze and organize data.
Strong attention to detail.
Excellent organizational, oral presentation and written and verbal communication skills.
Proficiency in MS Office products, including PowerPoint, Excel and Word.
Ability to provide effective leadership and direction within an organization.
Meets and consistently maintains production standards for Claims Adjudication.

Physical & Working Environment

Typical Physical Demands.
Position requires a great amount of sitting and standing. Some lifting, stooping, bending, or reaching is required. May require lifting up to 15‐30 pounds. Requires manual dexterity sufficient to operate a computer, calculator and telephone. Requires normal range of hearing and vision. Requires the ability to type and file.

Typical Working Conditions.
Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. Work may be stressful at times. May occasionally work some irregular hours.