CLAIMS EXAMINER I MSO
$79,040–$79,040 year
On-siteBurlingame, California, United States
Job Summary
Conduct daily review, audit, examination, and adjudication of professional claims based on Medi-Cal, Medicare, and MSO Claims Manual guidelines. Perform pre-payment claim reporting reviews to identify processing errors before the weekly FFS payment cycle and correct NEMS in-house billing discrepancies. Respond to first-level provider inquiries regarding claims status and handle member billing issues while maintaining a weekly production standard of 750 claims. Assist the Claims Supervisor with health plan delegation oversight audits and provide feedback on testing system upgrades. Report system configuration flaws and payment errors to the department manager and MSO System Configuration team for resolution. Requires a 2-year degree or equivalent experience, fluent English proficiency, and strong analytical skills to manage detail-oriented tasks in a non-exempt role.
Required Qualifications
- Completion of a 2-year degree from an accredited University, may be substituted with relevant work experience in healthcare medical claims processing and examination field
- Excellent data entry skills
- Must be able to fluently speak, read and write English
Desired Qualifications
- Two years' experience in health insurance claims processing, examination, and adjudication preferred
- Working knowledge of managed care and/or healthcare claim reimbursement or medical billing in Medi-Cal and Medicare Advantage program preferred
- Working knowledge of State/Federal healthcare compliance requirements (HIPAA, AB1455, and ICE standards), particularly DHCS/Medi-Cal and/or CMS/Medicare guidelines preferred
- Working knowledge of medical terminology, standard code sets, and claim forms preferred
- Ability to operate PC based software programs or automated database management systems preferred
- Fluent in other languages are an asset
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