Providence Claims Examiner - Management Services Organization in Mission Hills, California
Providence is calling a Claims Examiner Management Services Organization (Full-Time/Day Shift) to Providence Medical Institute in Mission Hills, CA.
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We are seeking a Claims Examiner Management Services Organization who will require in-depth understanding of managed care systems and the ability to utilize those concepts when processing claims. Effective communication skills and a working knowledge of managed care and provider contracts are critical as are good judgment and decision-making skills. Strong interpersonal relations and team building skills are a requirement for internal and external purposes. Experience in managed care and all aspects of professional, hospital and ancillary claims payment process is important. Supporting the values of PH&S-CA and proven ability to use team concepts to enhance shared leadership philosophies are essential for the success of this position. The Claims Examiner is responsible for processing claims. This position reports to the Manager, Claims - Management Services Organization.
Perform job activities in accordance with PH&S-CA Mission and Core Values, maintaining confidentiality while creating and maintaining a work environment that affirms and fosters respect for human diversity.
In this position you will:
Batch and balance processed claims on a daily basis
Investigate and research specialized claims to determine patient eligibility, benefit coverage and authorizations
Identify and return non-clean claims to providers with specific requests enumerated so that a clean claim can be resubmitted for processing
Analyze and process each specialized claim for appropriate procedure / diagnosis code before adjudication
Review claims entry for appropriate adjudication in compliance with benefit coverage, vendor contract and appropriate disposition code
Ability to accurately deny unauthorized and ineligible claims after researching the submission
Carefully review claim appeals against all appropriate criteria and then make adjustments as necessary
Meet operating performance standards established by the MSO
Attend meetings as needed
Adhere to safety policies and standards
Required qualifications for this position include:
Bachelor's Degree in Health care administration, business administration or an equivalent area
Possess a clear set of personal, organizational and societal values
Knowledge of and commitment to the application of Catholic/Christian health care ministries, principles and values
Must have a working knowledge of health plan benefits, DOFR and claim payment guidelines, DMHC regulations, NCQA standards and Medicare fee schedules and policies
Skilled in investigating and researching specialized claims so that adjudication is accurate
Ability to read and interpret provider contracts and fee schedules
Must be proficient in the Claims module of the GE/IDX system
Ability to work collaboratively with other operational units within Providence Health & Services
Ability to perform at high level in an environment of rapid growth, constant change and sometimes ambiguous circumstances
Preferred qualifications for this position include:
3 years experience in claims processing
Work history within an independent physician association, management services organization or physician hospital organization
About the hospital you will serve:
Providence Health & Services is further developing its physician integration strategy. Historically, the largest asset has been Providence Medical Institute, a medical foundation that provides administrative and other support services to affiliated medical groups. Providence Medical Institute is expected to grow significantly in the next several years, bringing with it facilities, staff and physician growth to support that objective.
For information on our comprehensive range of benefits, visit:
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Claims
Location: California-Mission Hills
Req ID: 282851