Medicare Sr. Claims Examiner

Job Details

Main Office - Santa Barbara, CA

Fully Remote

Full Time

$25.63 - $35.89 Hourly

Claims

Description

Central Coast Hourly Range - $25.63 - $35.89

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

This position is responsible for: researching, correcting and responding to all D-SNP pended claims as well the review of Audit reports in a timely manner; determining whether a claim should be paid (in accordance with the policies and procedures) and maintaining correspondence for document procedure /medical/CPT/ HCFA codes; assuring all regulatory guidelines are being followed.

Duties and Responsibilities

Review, price and release claims associated with the assigned claim types (paper and electronic).

Review Manual Review reports that suspend for review for D-SNP claims.

Review audit reports for D-SNP claims and calls.

Analyze current processes and work with Supervisor to automate or improve quality where fit.

Assist with ideas for creation of SCF (System Change Forms) or QNXT equivalent when applicable.

Keep up to date on all D-SNP policies and provide materials for improvement projects within Department.

Assure all regulatory guidelines are being followed and monitored.

Maintain daily activity log.

Assist with the processing of claims.

Audit and report all billing & error trends found during the course of review and data entry.

Maintain processes and timelines required by AB1455 Claims Settlement Practices and DHCS Regulations.

Other duties and projects assigned.

Qualifications

Knowledge / Skills / Abilities

QNXT experience.

Strong knowledge of the D-SNP program.

Strong knowledge in dual eligible claims processing (Medi-Cal and Medicare D-SNP).

Prior experience in high volume production environment.

Good oral and written communication skills.

Attention to detail.

Medical terminology and/or coding experience is highly desirable.

Education and Experience

High school diploma or equivalent.

Five (5) years’ experience as a Claims Examiner.