Claims Examiner I - (NOT REMOTE)

Clever Care Health Plan is one of Southern California’s fastest-growing Medicare Advantage plans, dedicated to transforming the healthcare space. The Claims Examiner I will process non-complex claims, manage a caseload, and ensure accurate and timely claims adjudication while adhering to company policies.

Responsibilities

• Be familiar and comply with all company policies and procedures
• Effectively manages a caseload of 50-150 claims a day
• Initiates and conducts claim investigation in a timely manner
• Achieve claims processing standards for accurate and timely claims adjudication
• Maintain claims processing standards to meet performance appraisal goals
• Determines compensability of claims and administer benefits, based upon product benefits and CMS guidelines
• Manages medical treatment and medical billing, authorizing as appropriate, with requests for surgical treatment to be referred to supervisor prior to authorizing
• Communicates with provider regarding claims issues
• Computes and processes payment
• Finalizes all claims and obtains authority as designated
• Maintains documentation in file to reflect the status of and work being performed on the file
• Communicates appropriate information promptly to the client to resolve claims efficiently
• Involves supervisory staff when appropriate
• Adheres to all Company policies and procedures
• Participates in audits and file reviews, as needed
• Performs other duties as assigned to include but not limited to assisting Document Processing Associate
• Other duties as assigned, mailroom tasks

Skills

• Associate degree
• One (1) year related experience; or equivalent combination of education and experience
• Technical knowledge of statutory regulations and medical terminology
• Familiar with CMS claims payment, billing guidance
• Knowledge of CPT, HCPCS and ICD-10 diagnosis codes
• Strong analytical skills, including the ability to analyze and organize data
• Strong attention to detail
• Excellent organizational, oral presentation and written and verbal communication skills
• Proficiency in MS Office products, including PowerPoint, Excel, and Word
• Must be able to travel when needed or required
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs
• Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly
• Bachelor's degree in related field preferred

Company Overview