Claims Examiner I

Are you looking to work with a great company in Kern County? Do you have experience in Claims? Apply today!

Knowledge of:

Computerized on-line data entry systems; organizational structure of medical claims processing; medical terminology; HCPCS, CPT & ICD-10 coding, UB04 and CMS1500

Essential Functions

Resolve system suspended claims for:

• PCPs

• Labs

• Radiology

• Less complicated specialists

• Physical Therapy

** Deny inappropriate claims following policy guidelines.

** Prepare claims that must be routed to other departments for further review.

** Review difficult claims with guidance from Claims Supervisor.

** Responsible for identifying billing errors and possible fraudulent claims submissions.

** Obtain eligibility verification and other health insurance coverage by Internet or POS.

** Responsible for correct manual calculation of benefits when applicable.

** Responsible for identifying possible CCS eligible claims for further investigation.

** Report overpayment refund requests on SharePoint log