Claims Examiner

Job Number: 1276

Workplace Type:

Position Title: Claims Examiner

External Description:

Position Summary:

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.

 

General Duties/Responsibilities:

• 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

 

Supervisory Responsibilities:

None.

 

Minimum Requirements:

• 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.

 

1. 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.
2. 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.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Claims Examiner

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].