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Astrana Health · 1 day ago

Claims Examiner III

Monterey Park, CA

Full-time

Hybrid

Mid, Senior Level

$28/hr - $32/hr

3+ years exp

Astrana Health is a healthcare organization seeking a Claims Examiner III to join their Ops - Claims Ops department. The role involves analyzing, processing, and adjudicating claims while ensuring compliance with regulatory guidelines and company policies.

Health CareMedical

Growth Opportunities

Responsibilities

Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-10 codes, under the correct provider and member benefits

Review and process facility (UB-04) and professional claims (CMS-1500)

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

Process Medicare member claims based on DMHC and DHS regulatory legislature

Respond to and resolve provider and health plan claims inquiries and give resolution in a timely manner

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

Monitor and track age, pended, and open reports to maintain timeliness in claims processing based on individual work allocation reports

Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines

Participate in special projects, complete tasks assigned by management and attend meetings/conference calls as necessary

Loading and entering claims

Other duties as assigned

Qualification

Healthcare claims adjudicationICD-10 codingClaims processing guidelinesMicrosoft ExcelEz-cap Claims softwareVerbal communicationWritten communicationProblem-solvingTeamwork

Required

Must have at least 3 years of applicable healthcare claims adjudication experience within the managed care industry for a level I or II and at least 4 years for Senior level claims

Must be familiar with ICD-10, HCPCS, CPT coding, APC, ASC and DRG pricing, CMS, DMHC regulations, facility and professional claim billing practices

Must possess proficient filing, general clerical, verbal and written communication and presentations skills

Must be able to problem-solve, follow guidelines, multi-task, and work comfortably within a team-oriented environment

Ability to type with accuracy and speed of at least 35 wpm

Associate's degree (A. A.) or equivalent from two-year college or technical school; some college courses, or six months to one year related experience and/or training; or equivalent combination of education and experience