Claims Examiner – Managed Care

Requisition # HRC1062752

The Claims Examiner is responsible for accurately and consistently adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy. Process claims according to all CMS and DMHC guidelines. Investigate and complete open or pended claims. Meet production and quality standards.

Job Duties and Responsibilities:

• Responsible for efficiency standards for number claims completed and for accuracy of entries
• Handles in a professional and confidential manner all correspondence
• Supports core values, policies, and procedures
• Obtains and adjudicates medical claims for processing; reviews scanned, EDI, or manual documents for pertinent data on claim for complete and accurate information.
• Acquires daily workflow via reports or work queue and incoming phone calls
• Research claims for appropriate support documents
• Analyzes and adjusts data, figures out appropriate codes, fees and ensures timely filing and contract rates are applied
• Responds and documents resolution of inquiries from internal departments
• Assists Finance with researching provider information to resolve outstanding or stale dated check issues
• Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases

Education:

High school diploma/GED required. Bachelor’s degree in healthcare or related field preferred.

Experience:

Three (3) years of medical claims processing for Medicare and Commercial products and provider dispute resolution processing in an IPA, HMO and Hospital related setting required. Three (3) years of experience with processing all types of specialty claims such as Chemotherapy, Dialysis, OB and drug and multiple surgery claims required. Three (3) years of experience on an automated claims processing system (Epic Tapestry preferred) preferred.

Working Title:

Claims Examiner – Managed Care

Department:

MNS – Managed Care

Business Entity:

Medical Network

Job Category:

,Strategic Plan/Business Dev,Strategic Plan/Business Dev

Job Specialty:

Managed Care

Position Type:

Full-time

Shift Length:

8 hour shift

Shift Type:

Day

Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law. If you need a reasonable accommodation for any part of the employment process, please contact us by email at Applicant_Accommodation@cshs.org and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this email address.

Cedars-Sinai will consider for employment qualified applicants with criminal histories, in accordance with the Los Angeles Fair Chance Initiative for Hiring.

At Cedars-Sinai, we are dedicated to the safety, health and wellbeing of our patients and employees. This includes protecting our patients from communicable diseases, such as influenza (flu) and COVID-19. For this reason, we require that all new employees receive a flu vaccine based on the seasonal availability of flu vaccine (typically during September through April each year) as a condition of employment, and annually thereafter as a condition of continued employment, subject to medical exemption or religious accommodation. For the same reason, you may also be required to receive other vaccines such as COVID-19 as a condition of employment. Cedars-Sinai reserves the right to make modifications to its required list of vaccines as required by law and/or policy.

Apply Now Apply Later