Plans examiner serp_jobs.h1.location_city
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Plans examiner • santa clara ca
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Orange, CA is a premier healthcare provider specializing in Medicare and HMO services.With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize acc...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
Vice President of Sales, Health Plans.Innovative virtual care platform specializing in women's health for ages 40+.The Company is seeking a VP of Sales, Health Plans to spearhead the national expan...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
Mobile Phlebotomist / Paramedical Examiner.On-Call and At-Will equal Flexibility! You will choose the days and hours you wish to work and the areas you wish to work in.
You manage your calendar of ava...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
A municipal government agency in San José is seeking a Chief Investment Officer to lead investment strategies for its pension plans and work collaboratively with external professionals.Candidates m...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
Remote Claims Processing Associate.NTT DATA is seeking to hire a Remote Claims Processing Associate to work for our end client and their team.
In this role, the candidate will be responsible for : .Pr...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
Put your Insurance Experience to work – FROM HOME!.Our unique platform provides you with.WHAT YOU’LL LOVE ABOUT WAHVE.We created a welcoming place to work with friendly and professional...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
Financial Examiner, Examiner-In-Charge (EIC).The Financial Examiner, EIC will primarily perform financial examinations and regulatory consulting services for state insurance departments.This positi...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
A company is looking for a Claims Examiner to evaluate insurance claims and determine compensation.Key Responsibilities Review insurance claims for validity and compliance with policy terms Coll...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
Workers Compensation Claims Examiner | Va Jurisdiction | Remote.By joining Sedgwick, you'll be part of something truly meaningful.
It's what our 33,000 colleagues do every day for people around the ...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
Claims Examiner - Construction Defect.DUAL North America is seeking a Casualty Examiner for the Construction Defect Claims team.
At DUAL, Casualty Examiners play a critical role in managing and reso...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
Agile program management for Elixir, Legato v2 and consumer integrations.serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
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Claims Examiner I
Astiva Health, IncSan Jose, CA, USserp_jobs.job_card.full_time
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Vice President of Sales, Health Plans
ConfidentialSan Jose, CA, United Statesserp_jobs.job_card.full_time
Mobile Phlebotomist / Paramedical Examiner
Quest DiagnosticsMilpitas, California, United Statesserp_jobs.job_card.part_time
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Chief Investment Officer, Pension & Retirement Plans
City of San JoséSan Jose, CA, USserp_jobs.job_card.full_time
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Claims Examiner
NTT DATASan Jose, CA, USserp_jobs.job_card.full_time
Commercial Auto Claims Adjuster / Examiner - REMOTE
Work At Home Vintage ExpertsSan Jose, CA, USserp_jobs.filters.remote
serp_jobs.job_card.full_time +2
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Financial Examiner - EIC
RSMSan Jose, CA, USserp_jobs.job_card.full_time
Claims Examiner
VirtualVocationsSanta Clara, California, United Statesserp_jobs.job_card.full_time
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Workers Compensation Claims Examiner | VA Jurisdiction | Remote
SedgwickSan Jose, CA, USserp_jobs.filters.remote
serp_jobs.job_card.full_time
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Claims Examiner - Construction Defect
HowdenSan Jose, CA, USserp_jobs.job_card.full_time
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Project Manager (Risk, Resource plans, Cost estimates) | Sunnyvale, CA - Onsite
SamprasoftSunnyvale, CA, USserp_jobs.job_card.full_time
Claims Examiner I
Astiva Health, IncSan Jose, CA, USjob_description.job_card.variable_days_ago
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job_description.job_card.job_descriptionGood knowledge of CPT / HCPCS / ICD-10, and Revenue Codes, including modifiers. Assist customer service as needed to assist in claims resolution on calls from providers. Research authorizations and properly selects appropriate authorization for services billed. Coordinate with the claims clerks on issues related to the submission and forwarding of claims determined to be financial responsibility of another organization. Coordinate Benefits on claims for which member has another primary coverage Run monthly reports. Review pre and post check run. Regular and consistent attendance Other duties as assigned High School Diploma or GED required. 1 to 3 years of previous experience in a health plan, IPA or medical group. Strong understanding of the benefit process including member services or customer service. Demonstrated proficiency in MS Office (Excel, Word, Outlook, and PowerPoint). Able to navigate difficult situations with empathy, discretion, and professionalism. Strong understanding of Senior Medicare Advantage Health plans. Able to explain member benefits, answer questions and concerns using a "Customer Service First" attitude. Able to live our mission, vision, and values, Bilingual in another language (written and oral) preferred.
About Us : Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.
SUMMARY : Under the direction of the Vice President of Claims, this position is responsible for manual input and adjudication of claims submitted to the health plan. The ideal candidate will need to interpret and utilize capitation contracts, payor matrixes, subscriber benefit plan, and provider contracts; as well as resolving customer service inquiries, status calls, andclaim tracers.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following :
- Data enter paper claims into EZCAP.
- Review and interpret provider contracts to properly adjudicate claims.
- Review and interpret Division of Financial Responsibility (DOFR) for claims processing.
- Perform delegated duties in a timely and efficient manner.
- Verify eligibility and benefits as necessary to properly apply co-pays.
- Understands eligibility, enrollment, and authorization process.
- Knowledge of prompt payment guidelines for clean and unclean claims
- Process claims efficiently and maintains acceptable quality of at least 95% on reviewed claims.
- Meets daily production standards set for the department.
- Prepares claims for medical review and signature review per processing guidelines.
- Identify the correctly received date on claims, with knowledge of all time frames for meeting compliance for all lines of business.
Maintains good working knowledge of system / internet and online tools used to process claims
QUALIFICATION REQUIREMENTS : To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. 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.
EDUCATION and / or EXPERIENCE :