Job Details

Job Details Job Location: Burlingame, CA Salary Range: $34.37 - $38.85 Hourly

The Claims Examiner is responsible for the daily review, audit, examination, investigation, and adjudication of professional claims. Must exceed qualitative standards and meet quantitative production standards. Assist Claims Supervisor with health plan delegation oversight audits, MSO management reports, and other special projects as needed.

ESSENTIAL JOB FUNCTIONS:

• Perform the daily examination, auditing, and adjudication activities to submitted 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.
• Meet the quantitative production standard of 750 claims per week.
• Provide feedback on testing system upgrades and enhancements.
• Responsible for the daily review of simple pre-payment claims reports. Identify processing errors and make corrections prior to the weekly FFS payment cycle.
• Identify NEMS in-house billing errors and communicate with MSO Claims Supervisor and NEMS Billing Manager for correction.
• Identify claims payment errors and/or system configuration flaws during day-to-day operations, reporting to department manager/supervisor and MSO System Configuration team to correct/resolve them.
• Respond to first-level provider inquiries related to claims adjudication, denial, and payment status, and handle member billed issues when they arise.
• Assist in all pre and post audit activities for health plan's delegation oversight audits.
• Perform 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.
• Two years' experience in health insurance claims processing, examination, and adjudication preferred.
• Excellent data entry skills required.
• Working knowledge of managed care and/or healthcare claim reimbursement or medical billing in Medi-Cal and Medicare Advantage program preferred.
• Working knowledge of State/Federal healthcare compliance requirements (HIPAA, AB1455, and ICE standards), particularly DHCS/Medi-Cal and/or CMS/Medicare guidelines preferred.
• Working knowledge of medical terminology, standard code sets, 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.
• Fluency in other languages is 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).