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Claims Examiner/Provider Dispute Resolution Specialist - Managed Care

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Requisition # HRC1062754

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

Job Duties and Responsibilities:

  • Meets efficiency standards for number claims completed and for accuracy of entries.
  • Handles in a professional and confidential manner all correspondence.
  • Supports Cedars-Sinai Medical Network Services 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.
  • Acquires daily workflow via reports or work queue and incoming phone calls.
  • Research 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 required. Subject Matter Expert in AB1455. Understanding of CMS, DHCS and DMHC rules and regulations that govern claims payment practices and procedures. Advance knowledge of research protocols. Strong analytical, problem-solving skills and organizational skills. Effective writing and communication skills.


Working Title: Claims Examiner/Provider Dispute Resolution Specialist - Managed Care
Department: MNS - Managed Care
Business Entity: Medical Network
Job Category: Strategic Plan/Business Dev
Job Specialty: Managed Care
Position Type: Full-time
Shift Length: 8 hour shift
Shift Type: Day

Base Pay: $19.11 - $28.67

Our compensation philosophy

We offer competitive total compensation that includes pay, benefits, and other recognition programs for our employees. The base pay range shown above takes into account the wide range of factors that are considered in making compensation decisions including knowledge/skills; relevant experience and training; education/certifications/licensure; and other business and organizational factors. This base pay range does not include our comprehensive benefits package and any incentive payments that may be applicable to this role

Diversity and Inclusion at Cedars-Sinai

We are caretakers and innovators committed to the pursuit of equitable healthcare. But health equity is not possible without representation. Our commitment to diversity goes beyond demographics or checking boxes. Our people must reflect the diverse identities, experiences and geographies of the communities and patients we serve – because that’s what our patients, colleagues and communities deserve. Quality Care and Research—For All, By All.

Cedars-Sinai is an Equal Employment Opportunity 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) and COVID-19. 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 April each year) as a condition of employment, and annually thereafter as a condition of continued employment, subject to medical exemption or religious accommodation. For the same reason, you may also be required to receive other vaccines such as COVID-19 as a condition of employment. Cedars-Sinai reserves the right to make modifications to its required list of vaccines as required by law and/or policy.

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