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Cedars-Sinai Claims Examiner - Managed Care in 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. Processes claims according to all CMS and DMHC guidelines. Investigate and complete open or pended claims. Meet production and quality standards.

Essential Job Duties:

•Meets productivity standards for number claims completed

and for accuracy of entries.

•Handles in a professional and confidential manner all

correspondence.

•Supports CSMNS core values, policies, and procedures.

•Receives, and adjudicates medical claims for processing;

reviews scanned, EDI, or manual documents for pertinent data on claim for

complete and accurate information.

•Receives daily workflow via reports or work queue and

incoming phone calls.

•Researches claims for appropriate support documents.

•Analyzes and adjusts data, determines 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.

Education:

High school diploma or GED required.

Experience:

Three (3) plus years of medical claims processing for Medicare and

Commercial products and provider dispute resolution processing in an IPA, HMO

and hospital related setting. Knowledge of general claims processing

principles. Knowledge of CMS and UB coding. Experience with processing all

types of specialty claims such as Chemotherapy, Dialysis, OB and drug and

multiple surgery claims. Experience on an automated claims processing system

(Epic Tapestry preferred). Ability to interpret Health Plans Division of

Financial Responsibility for both IPA and Hospital Risk. Knowledge of medical

terminology, CPT, HCPCS, Revenue Codes and ICD-10 codes. Working knowledge of

coordination of benefits and Correct Coding Initiative edits. Knowledge and

understanding of federal and state statutes, laws, rules and regulations.

Flexible and detail oriented. Excellent verbal and written communication skills required.

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.

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