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Innovative Management Systems, Inc. · 2 days ago
Claims Examiner II/III
City of Industry, CA
Full-time
Onsite
Mid Level
$24/hr - $37/hr
3+ years exp
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Insider Connection @Innovative Management Systems, Inc.
Responsibilities
Identify authorizations and match authorization to claims and claim concerns.
Adjudicate claims in the correct financial banks. Identify dual coverage and potential third-party liability claims.
Determine out-of-network and out-of-area services or providers and process in accordance with company and governmental guidelines.
Understand and interpret health plan Division of Financial Responsibilities and contract verbiage.
Process all claims, eligible or ineligible, accurately conforming to quality and production standards and specifications in a timely manner.
Support other Examiners in adjudicating claims from payors.
Adjudicate Commercial, Medicare Advantage, and Medi-Cal claims.
Document resolution of claims to support claim payment and/or decisions.
Demonstrate professional behavior, good business judgment, and strong team interaction skills.
Troubleshoot and resolve inquiries pertaining to Claims Department from internal and external stakeholders.
Read and interpret provider contracts to ensure payment/denial accuracy.
Read and interpret Medicare Fee schedules.
Identify root causes of claims payment errors and report any issues pertaining to claims to Management.
Generate and develop reports which include but are not limited to root causes of provider disputes.
Collaborate with other departments and/or providers in successful resolution of claims related issues.
Assist in the creation of business rules and training in order for Claims Department to become more efficient and accurate.
Attend meetings as needed pertaining to Claims and provide feedback when requested.
Travelling may be required for check runs – active and valid driver license and car insurance are required.
Other projects and duties as assigned.
Qualification
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Required
High School diploma and equivalent work experience in the managed care industry is required.
3+ years of related claims processing in a managed care organization such as managed service organization, IPA, and/or Health Plan experience.
Claims processing for Medicare.
Knowledge in Medicare rules and regulations.
Knowledge of medical terminology.
Substantial practical knowledge and understanding of relevant business practices and applicable regulations/policies pertaining to Claims processing.
Knowledge of HCFA 1500 forms, CPT and ICD codes.
Experience in reading and interpreting DOFRs and Contracts.
Experience and knowledge in Microsoft Office applications, such as Word and Excel.
Understand division of financial responsibility for determination of financial risk.
Excellent and effective communication, interpersonal, and organization skills.
Multitasking skills.
Ability to be proactive and work independently.
Excellent written & oral communication skills.
Excellent computer and typing skills.
Excellent customer service and conflict resolution abilities.
Ability to maintain the highest standards of confidentiality and HIPAA.
Ability to work with a high degree of integrity to perform objective and constructive audits.
Ability to self-motivate to meet deadlines.
Cultivate strong working relationships with other internal and external stakeholders.
Ability to keep track of projects and deadlines, and follow up with any pending issues.
Ability to accept responsibility and possess the desire to learn new tasks and/or make processes more efficient.
Preferred
Medi-Cal Claims processing knowledge is a plus.
Benefits
PTO
PSL
Holidays
401(k)
Flexible Spending Account
Work/Life Balance
Unpaid Time Off
Company
Innovative Management Systems, Inc.
IMS delivers Practice Management and Administrative Services to individual physicians, group practices, FQHCs, and hospitals.
11-50 employees
Funding
Current Stage
Early StageCompany data provided by crunchbase
