Claims Examiner - Los Angeles, CA

L.A. CARE HEALTH PLAN serves more than 800,000 people in Los Angeles County. We are the nation’s largest public health initiative – dedicated to helping Los Angeles County residents obtain health care coverage for their families from providers who understand and respect them. When you join our organization, you’re not just building a career; you’re helping care for the communities around you.

The CLAIMS EXAMINER is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes:

-- Processing claims for all lines of business, including complex claims;
-- Monitoring itemized billings for excessive charges, duplications, unbundling, and medical coding;
-- Determining prior authorization/precertification of services paid via system and/or health services;
-- Requesting and reviewing medical records as needed for basic information to validate billing information;
-- Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated;
-- Meeting and exceeding performance measurements for Claim Examiners as required by department to meet regulatory compliance.

QUALIFICATIONS:

EDUCATION / TRAINING:
AA Degree, BA or BS in business or healthcare-related field preferred

EXPERIENCE:
At least 3 years of healthcare claims processing experience, in a managed care environment.
Strong communication skills with excellent analytical and problem solving skills.
Ability to self-manage in a fast-paced, detail-oriented environment.
Extensive knowledge of medical terminology, standard claims forms, and physician billing coding.
Ability to read/interpret contracts, standard reference materials (PDR, CPT, ICD-9, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge.
Previous Medi-Cal claims processing experience, knowledge of State Department of Health Services regulations, and previous experience in EDI Claims processing a plus.
Moderate knowledge of Microsoft Word & Excel.
Ability to operate PC-based software programs or automated database management systems.

L.A. CARE is committed to employee training and development, with a special emphasis on quality improvement. Help promote health and prevent disease among the vulnerable populations within the communities of Los Angeles County.

For consideration, apply on-line. Please include salary history and requirement.

A great working environment and an exceptional/more than competitive benefits package are the icing on the cake!
REQUIREMENTS
SEE JOB DESCRIPTION