Claim Representative - Claims

Company: St. Joseph Health Covenant Health
Location: Anaheim
Posted on: May 13, 2022

Job Description:

We are looking for a Claim Representative with $1,000 Sign-On Bonus for the Claims Department at Providence Medical Foundation. $1,000 Sign-on Bonus for eligible external candidates who meet all conditions for payment - this is in addition to the fantastic benefits and compensation package offered by Providence that begin on your first day of employment. Location: Anaheim, CAWork Schedule: Full time - 80 Biweekly HoursShift: 8-hour, Days Job Summary: Working under the direction of the Director, this position is responsible for consistently and accurately adjudicating all contracted professional capitated claims with fee- for-service carve outs and, contracted fee-for-service claims for both Commercial and Senior plans within the timeliness and accuracy standards set forth by CMS, Department of Managed Care, AB1455 and the Claims Department polices and procedures. Essential Functions: + Reviews and processes all contracted capitated claims and fee-for-service PCP administration fee for-service claims paid and or denied while achieving and maintaining a 95% accuracy rate.+ Reviews and processes claims acknowledgment, payment and denial as set forth by CMS, Healthplans and departmental policy and procedures while achieving and maintaining a 95% timeliness standards.+ Achieving and maintain 95% production requirements per claim type utilizing departmental policy and procedures as established per Healthplan and Network.+ Recognizes inappropriate CPT, ICD-9 and HCPCS codes and accurately research member eligibility, duplicate claims submissions, out of network services, out of area services and COB and adjudicate according to departmental procedures.+ Monitors and updates inventory reports in order to track claims in inventory and follows-up on all claims suspended for review purposes or additional information requests until claims are in a final status.+ Reviews and processes audit errors on a daily basis.+ Alerts Claims Management of all claims issues that would impact any Healthplan compliance. Skills: + Requires familiarity with computerized claims processing/transaction system.+ Knowledge of Microsoft windows operating environment required.+ Possess basic analytical and problem solving skills.+ Possess good written and verbal communications skills to communicate effectively with individuals at all levels of the organization.+ Ability to work under general supervision.+ Ability to work as a team player and have a professional demeanor.+ Possess excellent organization and prioritization skills.+ Requires 10-key by touch. Minimum Position Requirements: Experience: 2 years experience as a Claims Examiner in an IPA, Medical Group or Health Plan. Preferred Position Qualifications: Experience: + Experience within the Health Care Industry.+ IDX experience.Providence Medical Foundation (formerly St. Joseph Heritage Health) includes seven medical groups throughout Northern California, Orange County, High Desert and Los Angeles County. With 175 locations and nearly 4,000 caregivers (employees), Providence Medical Foundation has been continually recognized as a leader in quality, receiving top honors from various organizations, including the Orange County Medical Association for Physicians of Excellence and the Integrated Healthcare Association with distinction in clinical quality. Providence Medical Foundation provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Providence Medical Foundation complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and pany: Providence Medical FoundationCategory: Administrative ( Non-clinical)Req ID: R357465

Keywords: St. Joseph Health Covenant Health, Anaheim , Claim Representative - Claims, Other , Anaheim, California