Claims Examiner 2

Easterseals Southern California transforms lives every day. For over a century, Easterseals has championed inclusion and independence—delivering essential services like early childhood programs, autism services, employment and independent living support to more than 29,000 people each year. Through advocacy and education, we break barriers and create opportunities for the one-in-four Americans with disabilities. 

Responsible for auditing claims processing and billing activities, including pre- and post-billing reviews, to ensure accuracy, compliance, and adherence to organizational policies and regulatory requirements. Conducts root cause analysis, identifies process improvements, and recommends corrective actions to prevent recurrence. Monitors appeals processing for assigned accounts, supports special projects, and provides guidance to entry-level staff as needed.

Starting Pay Range: $29.33/hr. - $36.54.hr.

OVERVIEW OF POSITION: Responsible for the investigation, determination, and reporting of claims processing through auditing billing processes, including pre and post-billing activity. The Examiner will audit, conduct root cause analysis, identify issues and propose solutions to correct and prevent recurrence; he/she will assist management with implementation of measures to ensure claim processing and payment accuracy, and adherence to all applicable policies, standards, and regulations internal and external to the organization. Monitors and reviews appeals processing of assigned account(s). Provides assistance in special projects and guidance to entry level staff as required.

ESSENTIAL FUNCTION:

• Supports the quality assurance process by routinely auditing claims and claim processing activity. Reviews claims for irregularities, accuracy, completeness and/or other criteria; and related processes to ensure proper guidelines, procedures and techniques have been followed.
• Prior to submitting claim data to vendor for processing, the Examiner performs quality assurance review of designated claims following established auditing procedures; such reviews include but are not limited to verification of authorization for services provided, values entered in the system such as coding, data discrepancies, duplicate records. Documents and communicates findings, and escalates issues when necessary.
• Coordinates with billing vendor for oversight, investigation, and resolution activities; while working closely with internal team and supervisor. Routinely monitors provider contracted services from a quality assurance point of view to ensure vendor is adhering to contractual obligations, agreed upon procedures, and adequate performance. Analyzes reports and metrics of billing activity, identifies issues, gaps and inconsistencies; documents and reports findings and recommends solutions to immediate supervisor and management.
• Reviews department and overall revenue cycle processes to identify technical, operational, and cost reduction improvement opportunities on an ongoing basis and as assigned; including but not limited to: coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures. Makes recommendations to management and assists in the implementation of approved solutions.
• Assist supervisor with EHR system related tasks such as testing of new features, contract configuration validation, and other related duties.
• Assists with developing training materials (related to claim quality, workflow processes, policies and procedures) and participates in effective training, guidance and coaching of new hires, entry level examiners, and external parties such as provider network.
• Corresponds with vendors, network providers, insurance carriers, and team members, as necessary, soliciting and coordinating required information to complete or resolve specific actions related to billing processing, payments, appeals, resolution of issues, and operational improvement activities.
• Monitors and reviews claim denials, no response, and underpayments for assigned insurance carrier or accounts. Reviews, investigates, and corresponds with vendor to identify and resolve issues to ensure payment from insurance companies; creates solutions to reduce appeals.
• Creates and maintains records, specialized reports, and metrics of audits. Maintains detailed documentation, including methods and techniques selected for reviewing, analyzing and evaluating claims and claim processing; additionally, keeps record of identified issues, recommended solutions, and status of issue resolution.
• Supports the analysis of revenue and monetary discrepancies, and other ad-hoc analysis as required.
• Assists in internal and external audits and other ad hoc projects as required.
• Maintains positive and strong working relationships with insurance carriers, network providers, vendors, and internal teams to ensure collaborative relationships, quality assurance activities, and issue resolution.
• Maintains a strong knowledge of revenue cycle concepts and processes, latest developments, advancements and trends, as it relates to claim management and EHR systems, to allow her/him to easily identify, research, and resolve claim processing issues, and expedite payment from carriers.
• Other duties as assigned.

EDUCATION:

Bachelor’s degree in Healthcare Administration, or related field is preferred.|Completion of medical billing or coding program.|Health information management certifications preferred.

EXPERIENCE:

• 4 - 6 years of recent medical insurance/healthcare billing experience; including day-to-day interpretation and practical application of related policies and procedures, such as deductibles, copayments, coinsurance, out of pocket maximums, out of network deductibles and exclusions, with strong understanding of medical terminology.
• Previous experience as a medical claims examiner or auditor preferred.
• Or the combination of experience, education, and training to perform the job successfully.

KNOWLEDGE, SKILLS, ABILITIES:

• Demonstrated ability in claim investigation, quality assurance process, ad-hoc audits, claim reviews, claim auditing management, claim process improvement, and claim appeals; knowledge of claim settlement policies, and EOB interpretation.
• Highly organized with strong problem solving, analytical and critical-thinking skills. Proven time management and research capability. High level of accuracy. Able to work independently and as part of a team.
• Able to work under pressure meeting timelines, adapt to the workload, and provide high-quality results in a fast paced environment. Able to multitask effectively.
• Able to work under pressure meeting timelines, adapt to the workload, and provide high-quality results in a fast paced environment. Able to multitask effectively.
• Tech savvy. Highly proficient in Excel, utilizing formulas, filters, data analysis features, pivot tables, charts, etc.. Intermediate proficiency in Outlook, PowerPoint, and Word. In the job experience of EHR systems, medical insurance claims management software, and other related applications. Able to learn department specific technology and computer systems.
• Thorough knowledge of state, federal, and applicable regulations pertaining to EHR and HIPAA.
• Expertise with medical billing software or systems, and interacting with third party vendors.
• Ability to troubleshoot claims processing technical problem areas.
• Bilingual in English and Spanish is preferred.
• Ability to interpret and follow policies, procedures, and regulations.
• Ability to exercise discretion and maintain a high level of confidentiality with sensitive or confidential situations and documentation at all times.
• Strong oral and written communication, as well as interpersonal and issue resolution skills. Used to work cooperatively with a variety of individuals and/or groups internal and external to the organization, maintaining customer service orientation and professionalism at all times.
• Ability to obtain and maintain a criminal record/fingerprint clearance from the Department of Justice and Federal Bureau of Investigation per Easterseals Southern California and/or program requirements.
• Must pass all drug testing required by ESSC.

Carrying/Lifting: Occasional / 0-30 lbs.
Standing: Occasional / Up to 3 hours per day
Sitting: Constant / Up to 8 hours per day
Walking: Occasional / Up to 3 hours per day
Repetitive Motion/Activity: Keyboard activity, telephone use, writing
Visual Acuity: Ability to view computer monitor and read newsprint
Travel: None
Environmental Exposure: None