Claims Examiner II

　　Job Category: Claims

　　Department: Claims Integrity

　　Location:

　　Los Angeles, CA, US, 90017

　　Position Type: Full Time

　　Requisition ID: 10636

　　Salary Range: $55,245.00 (Min.) - $69,045.00 (Mid.) - $82,867.00 (Max.)

　　Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

　　Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

　　Job Summary

　　The Claims Examiner II is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes:

　　Processing claims for all lines of business.

　　Process all claims type as needed.

　　Monitoring itemized billings for excessive charges, duplications.

　　Ensuring that all work meets quality guidelines and is performed within acceptable time frames.

　　Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated.

　　Meeting and exceeding performance measurements for Claim Examiners as required by the department to meet regulatory compliance.

　　Assisting management with onsite training as needed.

　　Assist Claims Examiner III as needed for special requests.

　　Duties

　　Process incoming claims: Determine correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions; Process all claims eligible Or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner; Document provider claims/billing forms to support payments/decisions. Negotiate reimbursement amounts for out-of-network claims; Identify dual coverage, Potential third party savings/recovery; Maintain department databases used for report production and tracking on-going work; Claims will be processed within the contractual and/or regulatory time frames within or less than 45 working days and as supported by the departmental policies. (60%)

　　Perform special projects and ad-hoc reporting as necessary. Projects will be complete and reports will be generated within the specific time frame agreed upon at the time of assignment. (15%)

　　Assist management with in-house and on-site training as offered to employees, contracted partners and providers. (5%)

　　Work with internal departments to resolve issues preventing claims processing or enhancing processing capabilities. May assist in testing, changing, analyzing and reporting of specific enhancements. (5%)

　　Attend meetings as required. Claims Department/Operations Division will be represented at internal and external meetings. (5%)

　　Perform other duties as assigned. (10%)

　　Duties Continued

　　Education Required

　　High School Diploma/or High School Equivalency Certificate

　　Education Preferred

　　Associate's Degree

　　Experience

　　Required:

　　At least 0-2 years of healthcare claims processing experience in a managed care environment.

　　Preferred:

　　Previous Medi-Cal or Medicare claims processing experience and knowledge of AB1455 regulations.

　　Skills

　　Required:

　　Ability to operate PC-based software programs or automated database management systems.

　　Strong communication skills with excellent analytical and problem solving skills.

　　Ability to self-manage in a fast-paced, detail-oriented environment.

　　Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials (PDR, CPT, ICD-10, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge.

　　Moderate knowledge of Microsoft Word and Excel.

　　Licenses/Certifications Required

　　Licenses/Certifications Preferred

　　Required Training

　　Physical Requirements

　　Light

　　Additional Information

　　Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

　　L.A. Care offers a wide range of benefits including

　　Paid Time Off (PTO)

　　Tuition Reimbursement

　　Retirement Plans

　　Medical, Dental and Vision

　　Wellness Program

　　Volunteer Time Off (VTO)