27 applicants
Prospect Medical Systems · 2 days ago
Claims Examiner III
Orange, CA
Full-time
Onsite
Mid Level
3+ years exp
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Responsibilities
Enter claims information from CMS 1500 (professional) and UB-04 (facility) claims into the IDX claims system.
Process all level of claims including Professional, COB, surgery, skilled nursing, lab, Home Health, ER, hospital (in and outpatient), DME, Pharmacy and radiology claims by applying Prospect’s policy and procedures and all claim payment criteria.
Analyze complex claim issues and handle all adjustments for corrected claims or when additional information previously requested is received.
Identify and pend claims that require referrals to all support areas (eligibility, Medical management etc) for evaluation or correction of data, tracking these claims to ensure that they are returned and resolved within regulatory guidelines.
Achieve stringent quality goals of 98% administrative accuracy and 99% financial accuracy to contribute to achieving client performance expectations.
Achieve stringent productivity goals of 80/10 claims per day/hr. Initiate recovery of overpaid claims. Also any other duties as requested.
Qualification
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Required
High school diploma or equivalent required.
Three to five (3-5) years prior medical claims processing experience required.
Knowledge of general claims processing principles, CMS claims coding, and UB-04 claims coding, based on at least three to five (3-5) years experience in claims processing preferably in a managed care environment (IPA, MSO).
Benefits
Health Insurance
Company
Prospect Medical Systems
With approximately 9,000 physicians to serve our 660,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Arizona, Texas, and Rhode Island.
501-1,000 employees
Funding
Current Stage
Late StageLeadership Team
Jim Brown, MBA, MPH
Chief Executive Officer
L
Lily Kam
Chief Financial Officer
Company data provided by crunchbase
