Apply on Employer Site

Partnership HealthPlan of California · 2 days ago

Claims Examiner II

Sonoma County, CA

Full-time

Onsite

Entry Level

$30.38/hr - $36.46/hr

1+ years exp

Partnership HealthPlan of California is seeking a Claims Examiner II to review, research, and resolve claims for all Medi-Cal claim types. The role requires processing claims within established production and quality standards, generating provider communication, and supporting the Claims Department's needs for resolving pended claims.

Health CareInsuranceNon Profit

Culture & Values

Responsibilities

Reviews, researches, and resolves pended claims for Medi-Cal types: medical, ancillary, long term care, CHDP, encounter data, other coverage, and batch claims within established production and quality standards. Completes claims from the Batch Error Report and Batch Pass Report

Routes claims to appropriate Partnership departments and internal staff for additional review. Follows up and completes claims once response to request has been received

Follows established Partnership policies and procedures, Partnership Claims Operating Instruction Memorandums, State of California Medi-Cal Provider Manual guidelines, Title 22 regulations, and CMS guidelines when resolving pended claims

Generates claims correspondence as needed

Records daily production statistics and related activities on appropriate reports. Turns in all logs and reports to the Medi-Cal Claims Supervisor

Reviews all work audits in a timely manner and submits any adjustments and corrections within the allotted time frame

Supports Claims Department’s needs for resolving all pended claim types

Participates in special projects and assignments as required

Identifies and reports trends of pending claims that are increasing or processes that appear dated

Recognizes and gives feedback to management on procedure changes that would result in more efficient operations

Other duties as assigned

Qualification

Medi-Cal billingClaims processingCPT knowledgeICD-10 knowledgeOrganizationJudgementTactEffective communication

Required

High school diploma or equivalent

Minimum one (1) year in Medi-Cal billing and/or claims examining experience in an automated environment

Effective written and oral communication skills

Good organization skills

Ability to effectively exercise good judgement within scope of authority and handle sensitive issues with tact and diplomacy

Ability to stay focused on repetitive work and meet production and quality standards

Ability to accurately complete tasks within established timelines

Consistently meets production standards without compromising quality on all tasks

Ability to use a microcomputer keyboard

More than 95% of work time is spent in front of a computer monitor

When required, ability to move, carry, or lift objects of varying size, weighing up to 5 lbs

Preferred

Knowledge of claims processing and/or Medi-Cal billing

CPT and ICD-10 knowledge

Company

Partnership HealthPlan of California

Partnership HealthPlan of California is a non-profit community-based health care organization that contracts with the state to administer Medi-Cal benefits through local care providers to ensure Medi-Cal recipients have access to high-quality comprehensive cost-effective health care.

Founded in 1994

Fairfield, California, USA

1001-5000 employees