Claims Processor

Top Job

Located in Visalia, CA

Salary: 20.00-22.00

Job Title: Claims Processor I & II

Department: Claims (Operations)

Reports to: Medicare and Commercial Operations Manager

Status:  Non-Exempt

 

 

Position Summary:  

Responsible for consistently and accurately adjudicating claims in accordance with policies, procedures and guidelines as outlined by company policy. Process claims according to all Centers for Medicare and Medicaid Services (CMS), California Department of Managed Health Care (DMHC) and regulatory guidelines. Work is performed as instructed and consults with supervisor or lead as needed on all matters not specifically covered in the instructions or guidelines. Interactions are made in a friendly non-competitive environment.

 

Essential Functions:

• Regular and predictable on-site attendance.
• Read and interpret Division of Responsible Responsibility (DOFR), provider contracts, and LOAs for payment accuracy.
• Review pre-check run reports as assigned and exception reports.
• Analyze and identify trends and provide finding as necessary to management.
• Consistently meet established productivity, timeliness and quality standards.
• Accurately process professional and facility claims.
• Ability to handle reprocessing projects.
• Have the ability to work cross-functionally to solve claim issues.
• Ability to handle most claim types/issues that are submitted to the team you are supporting.
• Attend weekly department meetings.
• Complete timecard and other required documents for accurate payroll processing.
• Follow safety rules when performing all tasks.

 

Knowledge, Skills, and Abilities:

• Clerical – Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, and other office procedures and terminology.
• Mathematics – Knowledge of arithmetic, algebra, geometry, calculus, statistics, and their applications. Use mathematics to solve problems.
• English Language – Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
• Customer and Personal Service – Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
• Active Listening – Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
• Reading Comprehension – Understanding written sentences and paragraphs in work related documents.
• Speaking – Talking to others to convey information effectively.
• Critical Thinking – Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
• Oral Comprehension – The ability to listen to and understand information and ideas presented through spoken words and sentences.
• Written Comprehension – The ability to read and understand information and ideas presented in writing.
• Written Expression – The ability to communicate information and ideas in writing so others will understand.
• Mathematical Reasoning – The ability to choose the right mathematical methods or formulas to solve a problem.
• Near Vision – The ability to see details at close range (within a few feet of the observer).

Education and Experience:

• High school diploma or General Education Degree (GED) required.
• Must have been actively engaged in work as a Claims Processor for a minimum of one (1) year working on “Professional and Hospital claims.
• Solid experience with ICD9 and 10
• Knowledge of DOFR
• Cross trained in all LOBs

Work Activities, Styles, and Requirements:

• Getting Information – Observing, receiving, and otherwise obtaining information from all relevant sources.
• Interacting with Computers – Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.
• Processing Information – Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.
• Documenting/Recording Information – Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.
• Organizing, Planning, and Prioritizing Work – Developing specific goals and plans to prioritize, organize, and accomplish your work.
• Integrity – Job requires being honest and ethical.
• Attention to Detail – Job requires being careful about detail and thorough in completing work tasks.
• Dependability – Job requires being reliable, responsible, and dependable, and fulfilling obligations.
• Independence – Job requires developing one’s own ways of doing things, guiding oneself with little or no supervision, and depending on oneself to get things done.
• Cooperation – Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude.
• Schedule - Ability to work flexible schedules that may include holidays and weekends. A 40 hour work week will be considered normal. Extra hours, working non-scheduled hours and extra workdays may be required.
• Environment – Indoor with typical office environment approximately 100% of the time. Required to move (walk or drive) from one work location to another.

 

Physical Demands:

• Ability to walk, sit, stand, stoop, crouch and climb stairs.
• Ability to lift up to 10 pounds.

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