Claims Examiner II

Company: Partnership HealthPlan of California
Location: Fairfield
Posted on: March 16, 2023

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