Claims Examiner

🔥 0 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $55.9k - $73.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Claims Specialist

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WelbeHealth

WebsiteLinkedInAll Job Openings

501 - 1000 employees

⚕️ Healthcare Insurance

💰 $30M Series C on 2020-02

Healthcare Insurance

WelbeHealth is a healthcare organization that provides comprehensive medical care and personalized support to help seniors age well at home and in their communities. They offer a Program of All-Inclusive Care for the Elderly (PACE) which includes services such as medical care and coordination, dental, vision and hearing services, in-home care, prescription deliveries, transportation, physical therapy, meals, social activities, and more, often at no cost to eligible seniors. WelbeHealth's dedicated team prioritizes the needs of seniors by offering a coordinated approach to healthcare, ensuring access to highly skilled professionals across various areas of healthcare, and emphasizing patient-centered care. Their goal is to improve the quality of life for seniors by enabling them to live independently with robust support from a multidisciplinary team.

📋 Description

• Examine, review and process claims according to contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards • Assess appropriateness of returned, denied, or paid claims by reviewing and following contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards • Ensure claim timeliness processing standards are being met • Work alongside manager to establish and maintain claims processing rules that meet all regulatory and business requirements • Assist internal and external partners with questions related to claims decisions or claims statuses • Maintain a comprehensive understanding of claim processing guidelines at both the federal and state level

🎯 Requirements

• High School Diploma or Equivalency, professional experience may be substituted • Minimum of three (3) years of experience with processing, researching, and adjudicating claims in a complex managed care environment • Working knowledge of the health plan insurance industry and CPT/HCPCS procedure codes, and relevant federal and state regulations • Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee schedule, Diagnosis Related Groups (DRG), Multiple Procedure Payment Reduction (MPPR) and benefit interpretation and administration • In depth experience with Medicare and Medicaid claims processing • Demonstrated skills within Microsoft Office Applications & electronic claims processing systems • Strong organizational, analytical, communication, and time management skills

🏖️ Benefits

• Medical insurance coverage (Medical, Dental, Vision) • Work/life balance – we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, sick time • Advancement opportunities - We’ve got a track record of hiring and promoting from within, meaning you can create your own path! • And additional benefits