Claims Examiner III

Claims Examiner III

Department: Ops - Claims Ops

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Sarah Chan

Compensation: $28.00 - $32.00 / hour

Job Title:

Claims Examiner III
Department:
Ops - Claims Ops

• Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-10 codes, under the correct provider and member benefits
• Review and process facility (UB-04) and professional claims (CMS-1500)
• Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups’ and company policies and procedures
• Process Medicare member claims based on DMHC and DHS regulatory legislature
• Respond to and resolve provider and health plan claims inquiries and give resolution in a timely manner
• Review services for appropriateness of charges and apply authorization guidelines during claims processing
• Monitor and track age, pended, and open reports to maintain timeliness in claims processing based on individual work allocation reports
• Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines
• Participate in special projects, complete tasks assigned by management and attend meetings/conference calls as necessary
• Loading and entering claims
• Other duties as assigned

• Must have at least 3 years of applicable healthcare claims adjudication experience within the managed care industry for a level I or II and at least 4 years for Senior level claims
• Candidates with multi-product line claims adjustment experience, preferred
• Must be familiar with ICD-10, HCPCS, CPT coding, APC, ASC and DRG pricing, CMS, DMHC regulations, facility and professional claim billing practices
• Must possess proficient filing, general clerical, verbal and written communication and
  presentations skills
• Must be able to problem‑solve, follow guidelines, multi‑task, and work comfortably within a team‑oriented environment
• Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and Ez‑cap Claims adjudication software, preferred
• Ability to type with accuracy and speed of at least 35 wpm
• Associate's degree (A.
  
  A.) or equivalent from two‑year college or technical school; some college courses, or six months to one year related experience and/or training; or equivalent combination of education and experience

• Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr., Monterey Park, CA 91754.
• The total compensation target pay range for this role is: $28.00 - $32.00 per hour. The salary range represents our national target range for this role.

Astrana Health is proud to be an Equal Employment Opportunity and Affimative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need.

If you require assistance in applying for open positions due to a disability, please email us at humanre to request an accommodation.

Additional Information:

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.