Sr. Claims Examiner

Location: Orange, California US

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Job Number: 4161

Position Title: Sr. Claims Examiner

External Description:

Alignment Healthcare was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.

 

By becoming a part of the Alignment Healthcare team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community.

Position Summary:

Senior Claims Examiner is responsible for reviewing and adjudicating more complex medical claims based on provider and health plan contractual agreements and claims processing guidelines. Works on all claims adjustment projects as identified either during audits or provider inquiries. Sr. Examiner works closely with Network Management and other departments in resolving claim payment issues. Assists in review and preparation of cases for health plan and regulatory audits (including Part C/ODAG payment validation). Train staff as assigned by Management. Follows all internal processes and procedures to ensure activities are handled in accordance with departmental and company policies and procedures. Understand and abides by all the department and company’s policy and confidentiality.

 

General Duties/Responsibilities:

 

Essential duties and responsibilities include but are not limited to:

  1. Reviews and evaluates claims based on established processing and payment guidelines, regulatory and contractual agreements.
  2. Determines level of reimbursement based on established criteria, provider contract, or plan provisions.
  3. Works on claim adjustment projects as identified during audits or through provider inquiries.
  4. Performs payment adjustments due to system changes and/or retroactive contract rate changes.
  5. Works with Provider Customer Service team in resolving claims payment issues.
  6. Documents claim production information into system, as directed. Documents all non-standard processes in the claim notes.
  7. Identifies and reports adjudication inaccuracies that are related to system configuration, benefit inconsistency, and fee schedules.
  8. Meets and consistently maintains quality and productivity standards as defined by the Management.
  9. Actively participates in ongoing training to support company and department initiatives.
  10. Supports department initiatives in improving processes and workflow efficiencies
  11. Assists in preparing and reviewing cases for regulatory and other health plan audits.
  12. Assists in training of Claims Department staff.
  13. Adheres to all regulatory and company standards, as described in the Employee Handbook and departmental Policies and Procedures.
  14. Contributes to team effort by accomplishing related results as needed.
  15. Complies with company’s time and attendance policy.
  16. Promotes teamwork and cooperation with other staff members and management
  17. Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
  18. Performs additional related duties as assigned by Management

 

Supervisory Responsibilities:

None

 

Minimum Requirements:

 

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  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.

 

Minimum Requirements:

 

  1. Minimum Experience:
  • 5+ years claims examining all types of claims (professional, facility, ancillary), preferably in Medicare Advantage delegated model

 

  1. Education/Licensure:
  • Bachelor’s degree in healthcare management or related field, a plus

 

  1. Other:
  • Knowledge of and experience in claims processing systems (EZCAP preferred)
  • Working knowledge of standard claims coding such as CPT4, ICD9/10, DRG and HCPCS and familiarity with Correct Coding Initiative (CCI) edits.
  • Working knowledge of and ability to process all Medicare claim types including, but not limited to professional services, ambulance transportation, inpatient facility (DRG), Stop-Loss/ Outlier and outpatient facility (APC)
  • Understanding of Division of Financial Responsibility on how they apply to claims processing
  • Ability to research and reference Medicare online sites for fee schedule and coverage determination information.
  • Knowledge of medical terminology
  • Knowledge of claims processing requirements which include but not limited to eligibility, HMO benefit structures and coordination of benefits
  • Strong organizational skills and decision-making and attention to details
  • Ability to work well in a fast-paced and dynamic environment.
  • Proven problem-solving skills and ability to translate knowledge to the department
  • Strong verbal and written communication skills.
  • Proficiency in MS-Office programs (Outlook, Excel and Word)

 

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
  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

 

FLSA Status: Non-Exempt

Reports To:    Claims Manager

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

 

If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact [email protected].

 

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Sr. Claims Examiner

Company Profile:

Alignment Health was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.

By becoming a part of the Alignment Health team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community.

EEO Employer Verbiage:

Alignment requires all new hires to follow local and/or state requirements regarding the COVID-19 vaccine and booster.  If applicable, proof of vaccination and booster will be required as a condition of employment subject to legal exemptions.  This policy, which Alignment reserves the right to modify, is part of Alignment’s ongoing efforts to ensure the safety and well-being of its staff and community and to support public health efforts.

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact [email protected].

*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].