Claims Examiner II

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

ESSENTIAL JOB FUNCTIONS:

• Perform the daily examination, auditing and adjudication activities to submitted hospital and 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.
• Responsible for the daily review of complex pre-payment claims reports. Identify processing errors and make corrections prior to the weekly FFS payment cycle.
• Identify claims payment errors and perform claims revision/correct activities for repayment or deduction per Physician and/or Vendor Contract terms.
• Must meet quantitative production standard of 750 claims per week.
• Provides feedback on testing system upgrades and enhancements.
• Respond to complex provider inquiries related to claims adjudication, denial, and payment status and handle member billed issues when arise.
• Respond to first level provider inquiries related to claims adjudication, denial, and payment status and handle member billed issues when arise (when necessary).
• Responsible to prepare, review, and submit claims files and evidence documents for the annual delegation oversight audit(s) performed by Health Plan(s).
• Provide recommendations to Claims Manager on updating claims policies and procedures to meet turn-around-time and/or CMS/DHCS/MCP regulatory requirement.
• Assist in training the entry level Claims Examiner for claims auditing and adjudication activities, and other MSO staff with general claims information.
• Identify system configuration errors and flaws during day-to-day operation, report to department supervisor, manager and MSO System Configuration team to correct/resolve them.
• Identify auditing errors and/or training-related opportunities that will improve operational efficiencies and results.
• Provides information in response to the requests of patient, physician, insurance company or co-worker as appropriate.
• Prepares and interprets appropriate statistical reports.
• Performs other job duties as required by manager/supervisor and NEMS Management Team.