Claims Examiner III in Orange at Prospect Medical Systems

Date Posted: 8/1/2019

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    600 City Parkway West
    Orange
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    8/1/2019
  • Job ID:
    13472

Job Description



Claims Examiner III

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

Responsible for consistently and accurately adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy.  Process claims according to all CMS and DMHC guidelines. Review, research and process complex claims.  Handle recalculation of claims due to incorrect claim payments or where additional information has been received.  Investigate and complete open or pended claims.  Meet production and quality standards.



Job Responsibilities/Duties

  • Enter claims information from CMS 1500 (professional) and UB-04 (facility) claims into the IDX claims system.  Process all level of claims including Professional, COB, surgery, skilled nursing, lab, Home Health, ER, hospital (in and outpatient), DME, Pharmacy and radiology claims by applying Prospect’s policy and procedures and all claim payment criteria.    Analyze complex claim issues and handle all adjustments for corrected claims or when additional information previously requested is received.
  • Identify and pend claims that require referrals to all support areas (eligibility, Medical management etc) for evaluation or correction of data, tracking these claims to ensure that they are returned and resolved within regulatory guidelines. 
  • Achieve stringent quality goals of 98% administrative accuracy and 99% financial accuracy to contribute to achieving client performance expectations. 
  • Achieve stringent productivity goals of 80/10 claims per day/hr.  Initiate recovery of overpaid claims.  Also any other duties as requested.


Qualifications

Minimum Education: High school diploma or equivalent required.

Minimum Experience: Three to five (3-5) years prior medical claims processing experience required. Knowledge of general claims processing principles, CMS claims coding, and UB-04 claims coding, based on at least three to five (3-5) years experience in claims processing preferably in a managed care environment (IPA,MSO)

Req. Certification/Licensure: None.



Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol.  Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm.  For this reason, we require applicants to pass a screening for drug use as a condition of employment.  This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.



How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm



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