Medical Claims Examiner

Required Skills & Experience

Extensive knowledge of medical terminology, ICD9, ICD10, and CPT codes.

Extensive knowledge of Plan benefits, group insurance, and Medicare principals.

Knowledge of Coordination of Benefits rules.

Considerable knowledge of basic math.

Ability to maintain production standards in a detail oriented, quality conscious service environment.

Ability to work independently with minimal supervision.

Strong analytical abilities.

Good written and verbal communication skills

Job Description

A Medical Health Insurance Plan based in Los Angeles is in the immediate need of a Medical Claims Representative. The Medical Claims Representative will be responsible for speaking with members over the phone and troubleshooting any of the participants bills or claims. The Medical Claims Representative will be tasked with answering inquiries regarding EOBs as well as any other issues pertaining to medical claims. Once the candidate is up and running, promotions will become available. The right person for this job will have a background in either medical claims, insurance verifications/authorizations or medical billing.

Research and respond to scheduled reports and claim inquiries sent by Blue Card and Blue Cross representatives in a timely manner.

Investigate and adjudicate complex claim requests and claims requiring special handling, such as adjustments and complaints in accordance with Plan guidelines, policy contract language and departmental processes and standards.

Write letters to participants and providers requesting additional information when necessary.

Follow up on pending claims.

Work with Eligibility Department to resolve eligibility problems, add or delete dependents, address changes, etc.

Act in accordance with all HIPAA Privacy and Security guidelines to ensure confidential handling of protected health information.

Answer phone calls from participants and providers when necessary.

Regular, predictable, and reliable attendance is required.

Ability to accept direction and developmental guidance from supervisor.

Ability to work effectively with individuals at all levels.

Compensation:

$20/hr to $22/hr.

Exact compensation may vary based on several factors, including skills, experience, and education.

Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.