Claims Examiner I

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Imperial Management Administrators Services

This position is responsible for analyzing and validating claim data elements and claims processing. The incumbent is responsible for adhering to the regulator and internal processing guidelines in conjunction with the company’s policies and procedures related to claims adjudication. Highly knowledge understanding of EZ-CAP relative to claims payments. Your efforts will support the accurate & timely payment of claims.

ESSENTIAL JOB FUNCTIONS:

1.    Process non-institutional claim types.

2.    Process basic claims to an adjudicated status.

3.    Analyze, process, research, adjust and adjudicate simple claims timely and accurately with the use of accurate procedure/revenue and ICD-10 codes, under the correct provider and member benefits, i.e., co-payment, deductible, etc.

4.    Analyze and process claims from providers based on provider contractual agreement, health plan division of financial responsibility, claim processing guidelines, and company policies and procedures.

5.    Perform thorough review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services.

6.    Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups and company policies and procedures.

7.    Process Medicare and Medi-Cal member claims based on DMHC and DHS regulatory legislature.

8.    Calculate and apply usual, customary, and reasonable rates on non-contracted provider claims, implement Medicare rates on senior member claims from non-contracted and ancillary providers.

9.    Respond to and resolve department/provider/health plan claims inquiries and give resolution in a timely manner.

10.  Review services for appropriateness of charges and apply authorization guidelines during claims processing.

11.  Review services for appropriateness of charges and medical necessity and ensure that prior authorization and pre-certification guidelines are implemented.

Ensure timely response to inquiries from claims monument team regarding payment of assigned claims duties.

EDUCATION/EXPERIENCE:

·         High school graduate or equivalent.

SKILLS/KNOWLEDGE/ABILITY:

·         EZ-CAP knowledge; or equivalent combination of education and experience.

To apply for this job please visit forms.office.com.