Job Details

Job Details Job Location: Burlingame, CA Salary Range: $42.79 - $48.75 Hourly

SUMMARY OF POSITION:

The MSO Lead Claims Examiner is responsible for the daily review, audit, examination, investigation and adjudication of all claims processed in the EZCAP system, to ensure qualitative standard. Responsible to prepare and review audit files and documents prior to submission to external auditors from contracted health plans, DHCS, and CMS. Assist Claims Manager with MSO management reports, monitor daily/weekly productivity and accuracy, training and retraining of claims processing guidelines, and other special projects as needed.

ESSENTIAL JOB FUNCTIONS:

• Perform the daily examination, auditing and adjudication activities to submitted hospital and professional claims based on established utilization criteria, Medi-Cal and/or Medicare guidelines, member's Evidence of Benefit, and policies and procedures outlined in the MSO Claims Manual.
• Responsible for the daily review of complex pre-payment claims reports. Identify processing errors and make corrections prior to payment.
• Responsible to monitor and manage Claims Turn-Around-Time (TAT) to meet team goal and AB1455 requirements.
• Responsible to monitor claims productivity and accuracy level to meet team goal and AB1455 requirements.
• Assists Claims Manager to interpret claims statistical and analytical reports and identifies potential errors and/or area of improvement to promote workflow efficiency.
• Assists the PDR Specialist in researching and resolving provider claims and payment disputes according to AB1455 requirement and report status to health plan(s).
• Respond to complex provider inquiries related to claims adjudication, denial, and payment status and handle member billed issues when arise.
• Respond to first level provider inquiries related to claims adjudication, denial, and payment status and handle member billed issues when arise (when necessary).
• Responsible to prepare, review, and submit claims files and evidence documents to external auditors for annual delegation oversight audit(s) performed by contracted Health Plan(s), DHCS, and CMS.
• Provide recommendations to Claims Manager on updating claims policies and procedures to meet turn-around-time and/or CMS/DHCS/MCP regulatory requirement.
• Perform training and re-training activities to all levels of Claims Examiner related to claims auditing and adjudication activities, and other MSO staff with general claims information.
• Identify system configuration errors and flaws during day-to-day operation, report to department manager and MSO System Configuration team to correct/resolve them.
• Identify auditing errors and/or training-related opportunities that will improve operational efficiencies and results; manages workflow of prospective and retrospective audits.
• Provides information in response to the requests of patient, physician, insurance company or co-worker as appropriate.
• Performs other job duties as required by manager/supervisor and NEMS Management Team.

QUALIFICATIONS:

• Completion of a 2-year degree from an accredited University, may be substituted with relevant work experience in healthcare medical claims processing and examination field.
• Minimum six years' experience in health insurance claims processing, examination, adjudication, and auditing.
• Strong knowledge of managed care and/or healthcare claim reimbursement or medical billing in Medi-Cal and Medicare Advantage program required.
• Working knowledge of State/Federal healthcare compliance requirements (HIPAA, AB1455, and ICE standards), particularly DHCS/Medi-Cal and CMS/Medicare guidelines required.
• Working knowledge of medical terminology, standard code sets including CPT, HCPCS, ICD, POS, and claim forms.
• Strong English communication skills with strong analytical and problem solving skills.
• Ability to self-manage in a detail oriented environment.
• Ability to operate PC based software programs or automated database management systems preferred.
• Good organization and prioritization skills, outstanding in time management.

LANGUAGE:

• Must be able to fluently speak, read and write English.
• Fluent in other languages are an asset.

STATUS:

• This is an FLSA NON-exempt position.
• This is not an OSHA high-risk position.
• This is a Full Time position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).