Claims Examiner II

Overview

To review, research, and resolve claims for all Medi-Cal claim types within established production and quality standards, including manual processing. Completes and processes claims and claims worksheets. Creates appropriate documentation that reflects the actions taken and status of the claim. Generates provider communication, such as letters, as necessary. Routes and tracks claims requiring review by other staff and departments, and processes when possible.

Claims Examiner II is distinguished from Claims Examiner I by a higher level of autonomy and experience, as well as an ability to process a wider range of claim types.

• Reviews, researches, and resolves pended claims for Medi-Cal types: medical, ancillary, long term care, CHDP, encounter data, other coverage, and batch claims within established production and quality standards. Completes claims from the Batch Error Report and Batch Pass Report.
• Routes claims to appropriate Partnership departments and internal staff for additional review. Follows up and completes claims once response to request has been received.
• Follows established Partnership policies and procedures, Partnership Claims Operating Instruction Memorandums, State of California Medi-Cal Provider Manual guidelines, Title 22 regulations, and CMS guidelines when resolving pended claims.
• Generates claims correspondence as needed.
• Records daily production statistics and related activities on appropriate reports. Turns in all logs and reports to the Medi-Cal Claims Supervisor.
• Reviews all work audits in a timely manner and submits any adjustments and corrections within the allotted time frame.
• Supports Claims Department’s needs for resolving all pended claim types.
• Participates in special projects and assignments as required.
• Identifies and reports trends of pending claims that are increasing or processes that appear dated.
• Recognizes and gives feedback to management on procedure changes that would result in more efficient operations.
• Other duties as assigned.

High school diploma or equivalent; minimum one (1) year in Medi-Cal billing and/or claims examining experience in an automated environment.

Effective written and oral communication skills. Good organization skills. Knowledge of claims processing and/or Medi-Cal billing, CPT, and ICD-10 knowledge preferred.

Ability to effectively exercise good judgement within scope of authority and handle sensitive issues with tact and diplomacy. Ability to stay focused on repetitive work and meet production and quality standards. Ability to accurately complete tasks within established timelines. Consistently meets production standards without compromising quality on all tasks.

Ability to use a microcomputer keyboard. More than 95% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 5 lbs.

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices;
• Abide by the Health Plan’s policies and procedures, as they may from time to time be updated.

$30.38 - $36.46

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.