SCAN Health Plan Careers – Claims Examiner, Sr (SCAN Temp). Those Candidate Are Interested to the Following Recruitment and Completed the All Eligibility Criteria Can Read the Full Details Before Apply Online.
Company Name: SCAN Health Plan
Job Position: Claims Examiner
Job Location: Long Beach, CA
The Job: Process contracted and non-contracted provider claims accurately and in a timely manner, meeting established department and company guidelines for quality, turnaround time and accuracy.
- Review and evaluate claims for appropriate coding against charges that are being billed.
- Determine level of reimbursement based on established criteria, provider contract, or plan provisions.
- Generate appropriate member and provider denials based on established departmental guidelines and training. Ensure corresponding denial letters are accurate.
- Document all non-standard processes in the claim notes.
- Identify and report adjudication inaccuracies that are related to system configuration, benefit inconsistencies, and fee schedules.
- Consistently meet individual performance metrics to ensure department quality and productivity standards are met.
- Work assigned cases through SCANs workflow system, apply correct status attributes to track and trend issues. Notate cases with required detail to ensure that others understand status of case and final resolution.
- Follow policies and procedures in order to maintain efficient and compliant operations; communicate suggestions for improvement and efficiencies to management; identify and report problems with workflows following proper departmental procedures; and actively participate in departmental staff meetings and training sessions.
- Provide a high level of customer service to members, providers, as well as internal customers by consistently meeting and/or exceeding team expectations including but not limited to quality, productivity and attendance.
- Follow all appropriate Federal and State regulatory requirements and guidelines applicable to SCAN Health Plan operations or as documented in company policies and procedures.
- Contribute to overall department success by participating in department initiatives, effective communication and collaboration with all members of the SCAN team through knowledge and idea sharing, take ownership to identify and report issues to appropriate management staff for resolution and work actively with the SCAN team to improve the support to our Members and Providers.
- Contribute to team effort by accomplishing related results as needed.
- Actively support the achievement of SCAN’s Vision and Goals.
- Associates Degree, or equivalent work experience required.
- 2+ years complex claims experience with Medicare Benefits, including fee-for service Medicare and Medicare Advantage Plans.
- 2+ years’ experience with Medicaid Benefits, including members that are dually covered by Medicare
- Knowledge of and ability to process all Medicare claim types including, but not limited to professional services, ambulance transportation, inpatient facility (DRG) and outpatient facility (APC).
- Knowledge of standard claims coding such as CPT, ICD-10, DRG and HCPCS.
- Ability to research and reference Medicare and Medicaid online sites for fee schedule and coverage determination information.
- Familiarity with Clean Claim Initiative (CCI) edits.
- Knowledge of and willingness to comply with the provisions of the Health Insurance Portability and Accountability Act (HIPAA).
- Knowledge of coordination of benefits and NAIC guidelines, preferred.
- Knowledge of heath care benefits structures and insurance procedures, preferably as they exist in an HMO health care environment.
- Knowledge of and experience with an automated claim processing system(s).
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