Medical Claims Examiner

Job Summary
The Claims Examiner is key in the daily operations and processing of medical claims. The Examiner is responsible for the review and accurate payment of PPO health claims under the Health and Welfare Plan.

This is a full-time position based in Pasadena, CA. Essential job functions include but are not limited to:

• Accurate and timely adjudication of medical claims.
• Investigation/communication in order to obtain necessary information to complete claim.
• Review and interpretation of contract benefits and edit/audit resolution.
• Knowledgeable and have the ability to access all relevant mainframe systems and screens in order to process claims accurately.
• Ensure security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained.
• Ability to extract claims authorization and historical data from the claims system.

Qualifications

• A minimum of 3-5 years processing experience of PPO medical claims.
• Knowledge of CMS-1500 and UB04’s.
• Be well versed in medical terminology, CPT codes, ICD9, ICD10 and HCPCS reference materials.
• Broad understanding of professional and hospital billing practices.
• Familiarity with Medicare/COB/TPL claims processing.
• Must have the ability to recognize the correlation between the diagnosis and the services billed.
• Must be able to meet high production and quality assurance standards.
• Must be able to recognize and perform claim adjustments for processing.
• Must have excellent organizational skills and the ability to exercise independent judgment at all times.
• Familiarity of unbundling methods, COB and other overbilling methodologies.
• Excellent written and verbal communication skills.
• Bilingual a plus, but not required.
• Knowledge of the QNXT/Trizetto claims system is desirable, but not required.
• Knowledge of the Anthem Blue Cross WGS system is desirable, but not required.