Claims Examiner II
Company: Partnership HealthPlan of California
Location: Fairfield
Posted on: March 9, 2023
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Job Description:
POSITION PURPOSE To review, research, and resolve claims for all
Medi-Cal claim types within established production and quality
standards, including manual processing. Completes and processes
claims and claims worksheets. Creates appropriate documentation
that reflects the actions taken and status of the claim. Generates
provider communication, such as letters, as necessary. Routes and
tracks claims requiring review by other staff and departments, and
processes when possible. Claims Examiner II is distinguished from
Claims Examiner I by a higher level of autonomy and experience, as
well as an ability to process a wider range of claim types.
ESSENTIAL DUTIES AND 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 PHC departments and internal staff for
additional review. Follows up and completes claims once response to
request has been received. - Follows established PHC policies and
procedures, PHC 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. Education and
Experience: High school diploma or equivalent; minimum one (1) year
in Medi-Cal billing and/or claims examining experience in an
automated environment. Special Skills, Licenses and Certifications:
Effective written and oral communication skills. Good organization
skills. Knowledge of claims processing and/or Medi-Cal billing,
CPT, and ICD-10 knowledge preferred.
Keywords: Partnership HealthPlan of California, Fairfield , Claims Examiner II, Other , Fairfield, California
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