Claims Examiner III – Medi-Cal Managed Care

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🔥 0 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $28 - $35 / hour

⏰ Full Time

🟠 Senior

🔴 Lead

📋 Claims Specialist

👻 Ghost score 0%

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All Care To You

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2018

🏥 Healthcare

⚕️ Healthcare Insurance

💼 Consulting

Healthcare • Healthcare Insurance • Consulting

All Care To You is a Management Service Organization (MSO) dedicated to fostering a collaborative work environment grounded in knowledge, trust, growth, and respect. The company primarily operates within the hospitals and healthcare sector, offering a range of services that support healthcare providers and enhance patient care.

📋 Description

• Process, adjust, and adjudicate professional, institutional, and complex claims, primarily Medi-Cal Managed Care claims • Serve as a subject matter expert for Medi-Cal claims processing, reimbursement methodologies, delegated risk arrangements, and regulatory requirements • Review and apply provider contracts, benefit plans, divisions of financial responsibility, authorizations, and reimbursement methodologies for accurate adjudication • Validate diagnosis and procedure codes and ensure compliance with DHCS, DMHC, CMS, AB 1455, AB 1324, and other applicable regulations • Research, analyze, and resolve complex claims issues, payment discrepancies, provider disputes, grievances, escalations, and processing errors • Process claim adjustments, voids, reopenings, reconsiderations, overpayment recoveries, and underpayment corrections • Generate and document provider communications and required letters • Collaborate with Customer Service, Provider Relations, Configuration, Compliance, and other departments • Create and utilize Crystal and SQL reports for inventory management, operational efficiency, and regulatory turnaround compliance • Identify payment errors, configuration issues, and process improvement opportunities; recommend corrective actions • Participate in audits, regulatory reviews, workflow improvement initiatives, and special projects • Meet productivity and quality standards while maintaining accurate documentation in EZ-Cap and related systems • Assist with training, mentoring, check run preparation, and other departmental needs as assigned • Comply with company policies, procedures, and confidentiality requirements

🎯 Requirements

• 10+ years of claims adjudication experience with significant experience processing Medi-Cal managed care claims • Minimum 5 years of experience processing Medicare and Commercial claims • Experience using EZ-Cap required • Extensive knowledge of California Medi-Cal, Medicare, and Commercial reimbursement methodologies • Thorough understanding of DHCS, DMHC, CMS, and applicable state and federal claims regulations • Experience with delegated IPA, Medical Group, and capitated provider arrangements • Demonstrated experience resolving Provider Disputes (PDRs), claims appeals, grievances, and escalated claims issues • Strong understanding of AB 1455 Claims Settlement Practices • Strong understanding of AB 1324 Requirements • Strong understanding of Knox-Keene regulations • Strong understanding of timely filing requirements • Strong understanding of Coordination of Benefits (COB) • Strong understanding of claims payment and regulatory turnaround requirements • Knowledge of CPT, HCPCS, ICD-10, DRG, APC, ASC, and other reimbursement methodologies • Proficient in outpatient PPS, inpatient DRG, interim rate payment methodologies, and other reimbursement structures applicable to Medi-Cal, Medicare, and Commercial products • Strong analytical, problem-solving, and claims research skills

🏖️ Benefits

• 100% employer paid medical, vision, dental, and life coverage • Paid holiday, sick time, and vacation time • 401k plan • Additional employee paid coverage options • Fully remote work environment • Flexible work environment and schedules