Claims Examiner

Job Description

Work Boldly. Live Brilliantly.

At AltaMed, we don’t just serve our communities, we are part of them. We have raised the expectations of what a community clinic can deliver because we think quality care is for everyone. And, we are determined to provide it no matter the challenges because this is more than a job. It’s the calling of our lives and it compels us to keep moving forward.

Job Overview

A Claims Examiner is responsible for analyzing and the adjudication of medical claims as it relates to managed care. Performs payment reconciliations and/or adjustments related to retroactive contract rate and fee schedule changes. Resolve claims payment issues as presented through Provider Dispute Resolution (PDR) process or from claims incident/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payments. Generates and develop reports which include but not limited to root causes of PDRs and Incidents. Collaborates with other departments and/or providers in successful resolution of claims related issues.

Minimum Requirements

1. HS Diploma or GED

2. 3+ years of Claims Processing experience in a managed care environment.

3. Must be knowledgeable of Medi-cal regulations.

4. Preferred knowledge of Medicare and Commercial rules and regulations.

5. Knowledge of medical terminology.

6. Must have an understanding to read and interpret DOFRs and Contracts.

7. Must have an understanding how to read a CMS-1500 and UB-04 form.

8. Must have strong organizational and mathematical skills.

Benefits & Career Development

• Medical, Dental and Vision insurance
• 403(b) Retirement savings plans with employer matching contributions
• Flexible Spending Accounts
• Commuter Flexible Spending
• Career Advancement & Development opportunities
• Paid Time Off & Holidays
• Paid CME Days
• Malpractice insurance and tail coverage
• Tuition Reimbursement Program
• Corporate Employee Discounts
• Employee Referral Bonus Program
• Pet Care Insurance