Claims Examiner I

About Us: Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.

SUMMARY: Under the direction of the Vice President of Claims, this position is responsible for manual input and adjudication of claims submitted to the health plan. The ideal candidate will need to interpret and utilize capitation contracts, payor matrixes, subscriber benefit plan, and provider contracts; as well as resolving customer service inquiries, status calls, andclaim tracers.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

• Data enter paper claims into EZCAP.

• Review and interpret provider contracts to properly adjudicate claims.

• Review and interpret Division of Financial Responsibility (DOFR) for claims processing.

• Perform delegated duties in a timely and efficient manner. • Verify eligibility and benefits as necessary to properly apply co-pays.

• Understands eligibility, enrollment, and authorization process. • Knowledge of prompt payment guidelines for clean and unclean claims

• Process claims efficiently and maintains acceptable quality of at least 95% on reviewed claims.

• Meets daily production standards set for the department.

• Prepares claims for medical review and signature review per processing guidelines.

• Identify the correctly received date on claims, with knowledge of all time frames for meeting compliance for all lines of business.

Maintains good working knowledge of system/internet and online tools used to process claims

• Good knowledge of CPT/HCPCS/ICD-10, and Revenue Codes, including modifiers.

• Assist customer service as needed to assist in claims resolution on calls from providers.

• Research authorizations and properly selects appropriate authorization for services billed.

• Coordinate with the claims clerks on issues related to the submission and forwarding of claims determined to be financial responsibility of another organization.

• Coordinate Benefits on claims for which member has another primary coverage

• Run monthly reports.

• Review pre and post check run.

• Regular and consistent attendance

• Other duties as assigned

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:

• High School Diploma or GED required.

• 1 to 3 years of previous experience in a health plan, IPA or medical group.

• Strong understanding of the benefit process including member services or customer service.

• Demonstrated proficiency in MS Office (Excel, Word, Outlook, and PowerPoint).

• Able to navigate difficult situations with empathy, discretion, and professionalism.

• Strong understanding of Senior Medicare Advantage Health plans.

• Able to explain member benefits, answer questions and concerns using a "Customer Service First" attitude.

• Able to live our mission, vision, and values,

• Bilingual in another language (written and oral) preferred.