Location: Orange, California US
Job Number: 1267
Position Title: Claims Examiner
Claims Examiner 1 reviews and adjudicates claims based on provider and health plan contractual agreements and claims processing guidelines. Follows all internal processes and procedures to ensure activities are handled in accordance with departmental and company policies and procedures. Excellent knowledge of claims processing rules. Institutional claims payment methodologies desirable. Maintains production standards as established by management to meet ‘time to pay’ requirements and, in addition, maintains high quality standards to ensure payment integrity. Independently works suspended claims on a daily basis. Upholds confidentiality of claims.
- Performs claim review, data entry, processing and adjudication of claims
- Reviews claims for data and payment accuracy
- Finalizes claims for denial of payment
- Review claims for fraud, waste or abuse and notifies management of such findings
- Updates systems or other documentation methods as needed
- Other Duties as Assigned
- 2+ Years of experience in medical claims processing
- Proven problem solving skills and ability to translate knowledge to the department
- Extensive experience and skills with Microsoft Office Products
- Ability to multitask
- Strong Organizational Skills
- Attention to Detail
- Ability to use 10 key
- Background in Medicare HMO and/or Medical Group/ IPA claims preferred
- Extensive knowledge of the Medicare payment methodologies
- Familiarity with CMS regulatory requirements
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
- The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Location City: Orange
Location State: California
Community / Marketing Title: Claims Examiner
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.
EEO Employer Verbiage:
Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.
If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact firstname.lastname@example.org.