Cedars-Sinai Claims Examiner - Managed Care in El Encino, California
The Claims Examiner is responsible for accurately and consistently adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy. Process claims according to all CMS and DMHC guidelines. Investigate and complete open or pended claims. Meet production and quality standards.
Job Duties and Responsibilities:
Responsible for efficiency standards for number claims completed and for accuracy of entries
Handles in a professional and confidential manner all correspondence
Supports core values, policies, and procedures
Obtains and adjudicates medical claims for processing; reviews scanned, EDI, or manual documents for pertinent data on claim for complete and accurate information.
Acquires daily workflow via reports or work queue and incoming phone calls
Research claims for appropriate support documents
Analyzes and adjusts data, figures out appropriate codes, fees and ensures timely filing and contract rates are applied
Responds and documents resolution of inquiries from internal departments
Assists Finance with researching provider information to resolve outstanding or stale dated check issues
Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases
High school diploma/GED required. Bachelor's degree in healthcare or related field preferred.
Three (3) years of medical claims processing for Medicare and Commercial products and provider dispute resolution processing in an IPA, HMO and Hospital related setting required. Three (3) years of experience with processing all types of specialty claims such as Chemotherapy, Dialysis, OB and drug and multiple surgery claims required. Three (3) years of experience on an automated claims processing system (Epic Tapestry preferred) preferred.
Working Title: Claims Examiner - Managed Care
Department: MNS - Managed Care
Business Entity: Medical Network
Job Category: Finance
Job Specialty: Accounting
Position Type: Full-time
Shift Length: 8 hour shift
Shift Type: Day
Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.