Job ID: 1801608
Reference Code: VI-Payers-Side Medical Claims 1+yr Exp
We are seeking an experienced Claims Examiner I with recent payer-side medical claims processing experience. This is a non-negotiable requirement. Candidates must have experience reviewing, adjudicating, auditing, and processing medical claims for a health plan, insurance carrier, HMO, managed care organization, or third-party administrator (TPA).
PROVIDER-SIDE EXPERIENCE ONLY (medical billing, accounts receivable, collections, patient financial services, or physician office billing) does not meet the minimum qualifications unless accompanied by direct payer claims adjudication experience.
Qualifications
High School Diploma or equivalent
Minimum 1 year of recent PAYERS SIDE Medical Claims Examiner or Claims Adjudication experience REQUIRED
Experience processing claims for a:
Health Plan
Insurance Carrier
HMO
Managed Care Organization
Third-Party Administrator (TPA)
Strong knowledge of:
Medical claims adjudication
Benefit interpretation
Provider contracts
Claims payment methodologies
CPT, HCPCS, and ICD-10 coding
CMS-1500 and UB-04 claim forms
Experience handling suspended, denied, adjusted, and manually reviewed claims
Computer Platforms & Systems
Claims processing systems
Electronic Health Records (EHR)
Practice Management Systems
Electronic Practice Management (EPM) systems
Online eligibility verification tools
SharePoint
Microsoft Office Suite
Equal Opportunity Employer / Disabled / Protected Veterans
The Know Your Rights poster is available here:
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf
The pay transparency policy is available here:
https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf
For temporary assignments lasting 13 weeks or longer, AppleOne is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required.
We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team.
AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program.
https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf
We also consider for employment qualified applicants regardless of criminal histories, consistent with legal requirements, including, if applicable, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment-qualified applicants with arrest and conviction records, including, if applicable, the San Francisco Fair Chance Ordinance. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.
Review, adjudicate, and process medical and facility claims accurately and within established service levels
Resolve suspended claims for:
Primary Care Providers (PCPs)
Laboratory services
Radiology services
Physical Therapy services
Specialist provider claims
Apply contract benefits, payer policies, and reimbursement guidelines
Deny claims appropriately based on established policies and procedures
Audit claims to ensure payment accuracy and regulatory compliance
Route complex claims to the appropriate department for further review
Identify billing errors, duplicate submissions, and potential fraudulent claims activity
Verify member eligibility and other insurance coverage using online resources
Calculate benefits manually when required
Identify potential CCS-eligible claims for further investigation
Report overpayment refund requests through SharePoint logs
Maintain productivity and quality standards
Comply with HIPAA and all applicable federal, state, and local regulations
Participate in quality improvement initiatives and departmental projects
Perform additional duties as assigned
Are you an experienced Claims Examiner, Claims Adjudicator, Health Plan Claims Processor, or Insurance Claims Specialist with PAYER SIDE claims processing experience?
If you have a proven background reviewing and adjudicating medical claims for a health plan, HMO, insurance carrier, or TPA, we want to hear from you.
Apply today and take the next step in your healthcare claims career.