Claims Examiner (US Health Insurance Claims)

CLAIMS EXAMINER
Job Description: The Claims Examiner processes routine and non-routine US health insurance claims, such as inpatient and outpatient, Medicare, commercial and Medi-Cal claims, using established claim standards, and departmental policies and procedures. He/she accurately evaluates and adjudicates exception claims in a timely manner and according to set standards; accurately evaluates and adjudicates professional, facilities, and ancillary claims as assigned, in a timely manner and according to set standards. This role is also responsible for adjudicating all types of claims, including appeals, adjustments, PDR in advance of specific health plan financial benefit matrixes.
• Remote set-up: candidate should be Philippines-based and will be reporting to a US-based company
• Work Shift: 8AM to 5PM Pacific Standard Time (8hrs)
• Employment Status: Independent Contractor

Qualifications:
• Should be based in the Philippines and willing to work remotely for a US-based company
• College degree is preferred
• Computer literate: MS Word, MS Excel expertise is required
• A minimum of 2-year claims examining experience is required
• Experience working with QuickCap or similar applications is preferred
• With excellent interpersonal/communication skills
• Experience in communicating with Health Plans in a professional and timely manner and experience with audits/regular reporting is a plus

Responsibilities include, but are not limited to:
• Accurately reviews, researches and analyzes professional, ancillary and institutional inpatient and outpatient claims
• Knowledge on CPT/HCPC and ICD-9/ICD-10 codes and guidelines
• Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims
• Comprehensive knowledge of various fee schedules and CMS prices for outpatient/inpatient institutional, ancillary and professional claims, including, but not limited to Medicare fee schedules, DRG, APC, ASC, SNF-RUG
• Ability to identify and report processing inaccuracies that are related to system configuration
Processes all types of claims, such as, HCFA 1500, outpatient/inpatient UB92, high dollar claims, COB and DRG claim
• Processes and adjudicates claims for payment accuracy or denial of payment according to Department’s policy and procedures
• Processes all claims accurately conforming to quality and production standards and specifications in a timely manner
• Documents resolution of claims to support claim payment and/or decision
• Makes benefit determinations and calculations of type and level of benefits based on established criteria and provider contracts
• Understands and interprets health plan Division of Financial Responsibilities and contract verbiage
• Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines
• Ability to prioritize, multitask and manage claims assignment within department goals and regulatory compliance and with minimal supervision
• Ability to make phone calls to Provider/Billing offices when necessary, based on department guidelines
• Requests additional information or follow up with provider for incomplete or unclean claims