Claims Examiner I MSO

The Claims Examiner is responsible for the daily review, audit, examination, investigation and adjudication of professional claims. Must exceed qualitative standard and meet quantitative production standard. Assist Claims Supervisor with health plan delegation oversight audits, MSO management reports, and other special projects as needed.

ESSENTIAL JOB FUNCTIONS:

• Perform the daily examination, auditing and adjudication activities to submitted professional claims based on established utilization criteria, Medi-Cal and/or Medicare guidelines, member's Evidence of Benefit, and policies and procedures outlined in the MSO Claims Manual.
• Must meet quantitative production standard of 750 claims per week.
• Provides feedback on testing system upgrades and enhancements.
• Responsible for the daily review of simple pre-payment claims reports. Identify processing errors and make corrections prior to the weekly FFS payment cycle.
• Identify NEMS in-house billing errors and communicate with MSO Claims Supervisor and NEMS Billing Manager for correction.
• Identify claims payment errors and/or system configuration flaws during day-to-day operation, report to department manager/supervisor and MSO System Configuration team to correct/resolve them.
• Respond to first-level provider inquiries related to claims adjudication, denial and payment status and handle member billed issues when arise.
• Assist in all pre and post audit activities for health plan's delegation oversight audits.
• Performs other job duties as required by manager/supervisor and NEMS Management Team.