Seeking a professional level Claims Examiner-Bilingual in Spanish preferred - $37/hr - Fremont, CA area
Must have 2 years minimum medical claims processing experience.
This position is an onsite opportunity with no remote or hybrid option.
As the Claims Examiner, your primary responsibility is to process multiple forms of insurance claims for active and retired participants in conformity with Plan benefits and provisions and claims department procedures, as well as to provide professional-level customer service. It calls for word processing and data entry ability, the capability to edit documents, and knowledge of Windows, Excel, and Access. The position requires at least two years of prior Claims Processing experience, the faculty to multi-task; as well as, to have commendable communication skills. Claims must be processed accurately and timely. This position works within the Claims Department and requires experience in online claims adjudication and a working knowledge of claims codes and descriptions, medical terminology, PPO provider guidelines, eligibility, limitations, exclusions, case management, and medical review.
This is a full-time position contract to hire.
ESSENTIAL FUNCTIONS, DUTIES AND RESPONSIBILITIES
Functions, duties, and responsibilities may include, but are not limited to the following:
- Must have two years of claims processing experience and basic knowledge and understanding of group benefit plans, and how they relate to claims processing; including plan benefits, eligibility, limitations, exclusions, etc.
- Must be able to develop knowledge and understanding of applicable Carrier’s computer systems (currently Anthem Blue Cross) to the extent necessary for online claims processing, data entry, and other related responsibilities.
- Must be able to accurately interpret plan benefits and process claims accordingly.
- Must be able to develop knowledge and understanding of PPO guidelines and procedures, coordination of benefits, Medicare, and supplemental plan benefits.
- Use various office machines, such as computers, ten-key calculators, photocopiers, fax, set-up spreadsheets, etc.
- Attend training sessions and staff meetings as requested.
- When performing Customer Service Representative responsibilities; (a) must be able to answer questions regarding eligibility and benefits for all Plans, provide concise and accurate information, quote directly from Plan documents, without giving advice, and (b) must keep accurate records of requests for eligibility and benefits and a written synopsis of each call and on-line documentation.
- Communicate with providers and participants by phone, correspondence/email, faxes, or in person.
- Assist Auditors, Managers, and other miscellaneous duties as assigned.
PHYSICAL/MENTAL DEMANDS
- The work is repetitive and requires sitting at a desk using a computer for extended periods of time.
- Requires concentration, attention to accuracy, and detail with the ability to mentally block out extraneous sounds and conversations.
- The work requires the ability to meet production requirements while maintaining high-quality standards.
- Must be able to maintain a consistent production level benchmark, as determined by the Department Supervisor.
KNOWLEDGE, SKILLS AND ABILITIES
- Must have a minimum of two years of current experience in processing medical and dental claims online.
- Must be familiar with HIPAA regulations and Health Care Reform requirements, medical terminology, C.P.T., I.C.D.A., Diagnosis Codes (ICD-9 & ICD-10), and H.C.P.C.S. codes.
- Must be able to re-calculate claims; perform (sometimes complicated) calculations, applying formulas using multiplication and percentages.
- Must become competent in the use of applicable Carrier’s computer systems (currently Anthem Blue Cross).
- Must develop a working knowledge of department locations and organization structure.
- Must have ‘excellent’ communication skills, both written and verbal, and possess analytical and critical thinking skills.
- Must be able to write legibly and input accurately.
- Must have ten key-by-touch skills, word processing, and data processing experience.
- Must be able to understand and follow moderately complex oral and written instructions.
- Must be able to organize tasks and time to ensure timely completion of all work.
- Must be detail-oriented.
- Must be flexible and willing to perform other duties as assigned.
- Must be able to work as a team member.
QUALIFICATIONS – TESTING
All Applicants will be given:
- A written & verbal Claims Examiner Test.
- Online timed general cognitive/reasoning/reading comprehension and vocabulary assessment tests.
- An online assessment test for proficiency in Microsoft Word, Excel, and Outlook.
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Job Type: Full-time
Pay: From $37.00 per hour
Expected hours: 37.5 per week
Schedule:
Work setting:
Education:
Experience:
- Medical claims specific: 2 years (Required)
Work Location: In person