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Claims Examiner - Managed Care

Requisition # 20000711 Apply Now

The Claims Examiner is responsible for accurately and consistently adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy.  Processes claims according to all CMS and DMHC guidelines.  Investigate and complete open or pended claims.  Meet production and quality standards.

Essential Job Duties:
• Meets productivity standards for number claims completed and for accuracy of entries.
• Handles in a professional and confidential manner all correspondence.
• Supports CSMNS core values, policies, and procedures.
• Receives, and adjudicates medical claims for processing; reviews scanned, EDI, or manual documents for pertinent data on claim for complete and accurate information.
• Receives daily workflow via reports or work queue and incoming phone calls.
• Researches claims for appropriate support documents.
• Analyzes and adjusts data, determines appropriate codes, fees and ensures timely filing and contract rates are applied.
• Responds and documents resolution of inquiries from internal departments.
• Assists Finance with researching provider information to resolve outstanding or stale dated check issues.
• Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases.

Education:

High school diploma or GED required.

 

Experience:
Three (3) plus years of medical claims processing for Medicare and Commercial products and provider dispute resolution processing in an IPA, HMO and hospital related setting. Knowledge of general claims processing principles. Knowledge of CMS and UB coding. Experience with processing all types of specialty claims such as Chemotherapy, Dialysis, OB and drug and multiple surgery claims. Experience on an automated claims processing system (Epic Tapestry preferred). Ability to interpret Health Plans Division of Financial Responsibility for both IPA and Hospital Risk. Knowledge of medical terminology, CPT, HCPCS, Revenue Codes and ICD-10 codes. Working knowledge of coordination of benefits and Correct Coding Initiative edits. Knowledge and understanding of federal and state statutes, laws, rules and regulations. Flexible and detail oriented. Excellent verbal and written communication skills required.

  • Working Title: Claims Examiner - Managed Care
  • Department: MNS - Managed Care
  • Business Entity: Medical Network
  • City: Encino
  • Job Category: Finance
  • Job Specialty: Accounting
  • Position Type: Full-time
  • Shift Length: 8 hour shift
  • Shift Type: Day
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Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law. If you need a reasonable accommodation for any part of the employment process, please contact us by email at Applicant_Accommodation@cshs.org and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this email address.

Cedars-Sinai will consider for employment qualified applicants with criminal histories, in accordance with the Los Angeles Fair Chance Initiative for Hiring.

At Cedars-Sinai, we are dedicated to the safety, health and wellbeing of our patients and employees. This includes protecting our patients from communicable diseases, such as influenza (flu). For this reason, we require that all new employees receive a flu vaccine based on the seasonal availability of flu vaccine (typically during September through March each year) as a condition of employment, and annually thereafter as a condition of continued employment.

About Our Location

Encino, California

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