Claims Examiner I

This position operates on a hybrid work schedule. This position will require 3 days onsite at the Huntington Beach office.

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We?

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.

Why Join Us?

We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

Under close supervision, Claims Examiner I process non-complex paper or electronic claims, handling from inception to conclusion within established authority and guidelines.

This position requires considerable interaction with clients, claimants on the phone, with management, other Claims Examiners, and other staff in the office; therefore, consistently being at work in the office or home office location as applicable, in a timely manner, is inherently required of this position.

Functions & Job Responsibilities

• Be familiar and comply with all company policies and procedures.
• Effectively manages a caseload of 50-150 claims a day
• Initiates and conducts claim investigation in a timely manner.
• Achieve claims processing standards for accurate and timely claims adjudication.
• Maintain claims processing standards to meet performance appraisal goals.
• Determines compensability of claims and administer benefits, based upon product benefits and CMS guidelines.
• Manages medical treatment and medical billing, authorizing as appropriate, with requests for surgical treatment to be referred to supervisor prior to authorizing.
• Communicates with provider regarding claims issues
• Computes and processes payment.
• Finalizes all claims and obtains authority as designated.
• Maintains documentation in file to reflect the status of and work being performed on the file.
• Communicates appropriate information promptly to the client to resolve claims efficiently.
• Involves supervisory staff when appropriate.
• Adheres to all Company policies and procedures.
• Participates in audits and file reviews, as needed.
• Performs other duties as assigned to include but not limited to assisting Document Processing Associate.
• Other duties as assigned, mailroom tasks.