Claims Examiner II

Title: Claims Examiner II

Location: Fountain Valley

Department: Claims

Status: Full-Time

Shift: Days (8hrs) Predominantly Remote

Pay Range: $22.41/hr - $32.50/hr

MemorialCare is a nonprofit integrated health system that includes four leading hospitals, award-winning medical groups – consisting of over 200 sites of care, and more than 2,000 physicians throughout Orange and Los Angeles Counties. We are committed to increasing access to patient-centric, affordable, and high-quality healthcare; your personal contributions are integral to MemorialCare's recognition as a market leader and innovator in value-based and other care models.

Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration, and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation, and teamwork.

Position Summary

The Claims Examiner II accurately reviews, researches and analyzes professional, ancillary and institutional inpatient and outpatient claims.

Essential Functions and Responsibilities of the Job

1. Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines.
2. Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims.
3. Comprehensive knowledge of various fee schedules and CMS prices for outpatient/inpatient institutional, ancillary and professional claims, including, but not limited to Medicare fee schedules, DRG, APC, ASC, SNF-RUG. 
4. Ability to identify and report processing inaccuracies that are related to system configuration.
5. Process all types of claims, such as, HCFA 1500, outpatient/inpatient UB92, high dollar claims, COB and DRG claim.
6. Reviews. processes and adjudicate claims for payment accuracy or denial of payment according to Department’s policy and procedures.
7. Processes all claims accurately conforming to quality and production standards and specifications in a timely manner.
8. Documents resolution of claims to support claim payment and/or decision. 
9. Makes benefit determinations and calculations of type and level of benefits based on established criteria and provider contracts. 
10. Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.
11. Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines.
12. Adjudication of Commercial and Medicare Advantage claims.
13. Ability to prioritize, multitask and manage claims assignment within department goals and regulatory compliance and with minimal supervision.
14. Ability to make phone calls to Provider/Billing offices when necessary, based on department guidelines.
15. Requests additional information or follow up with provider for incomplete or unclean claims.
16. Ability to effectively communicate with External and Internal teams to resolve claims issues.
17. Ability to interact in a positive and constructive manner.

Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there’s more...Check out our MemorialCare Benefits for more information about our Benefits and Rewards.

Experience

1. Minimum of 5+ years’ experience in processing all types of professional, ancillary, and institutional claims in Managed Care.
2. Comprehensive knowledge of various fee schedules and CMS prices for professional, facility and ancillary claims.
3. Comprehensive knowledge of CPT, ICD-9 and ICD-10 codes, inpatient procedure coding, HCPCS, Revenue Codes, medical terminology and COB required.
4. Working knowledge of Claims Information systems.
5. Understands division of financial responsibility for determination of financial risk.
6. Type a minimum of 45 words per minute.

Education

High School diploma