Claims Examiner III

Physician Associates of the Greater San Gabriel Valley is looking for an experienced Claims Examiner to join our progressive organization.  At Physician Associates we are committed to being a learning organization with the focus of making a difference in the communities that we serve by providing an atmosphere of collaboration, communication and accountability.  If you are ready to make a difference at our organization and you meet the criteria below, please submit your resume as soon as possible, we look forward to meeting you.

 

Some of the Job responsibilities include adjudication of all types of managed healthcare facility and professional services claims in accordance with regulatory requirements, health plan benefit structures, established company adjudication and claim settlement policies and procedures as well as generally accepted industry standards. In addition, the qualified candidate will also be responsible for verifying or calculating appropriate payment for payable claims and inputs required payment information into claim’s system.  They will determine appropriate reasons for denial of claims that cannot be paid and inputs required denial coding into claim system.

 

The qualified candidate will possess a High School diploma or general education degree (GED).  A minimum of three (3) to five (5) years experience in adjudicating complex managed healthcare claims for a health plan, delegated payer (IPA/MSO) or third-party administrator. They must be familiar with medical terminology and must understand complex regulatory requirements for administration of commercial, Medicare, and Medi-Cal health benefits.  Must be able to read and understand health plan contracts and must be able to interpret and apply DOR grids.Must possess in-depth knowledge of diagnostic and procedural coding structures as well as standard industry default pricing methodologies including DRG, RBRVS, APC, and Medi-Cal. Must be familiar with standard healthcare billing forms (HCFA 1500 and UB-92).  Needs to be able to make basic mathematical calculations including addition, multiplication, division, and application of percentages.