Professional Claims Examiner II (Healthcare) - Ontario, California

    • Ontario, CA

Position Description

Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work.(sm)

Primary Responsibilities:

  • Provide expertise or general claims support by reviewing, researching, investigating, negotiating, processing and adjusting claims
  • Authorize appropriate payment or refer claims to investigators for further review
  • Analyze and identify trends and provides reports as necessary
  • Consistently meet established productivity, schedule adherence, and quality standards
  • Provide excellent customer service
  • Accurately process professional claims
  • Responsible for editing and adjusting of EDI claims
  • Analyze and adjudicate claims to ensure accurate payment
  • Interpret Fee for Service (FFS) and capitated provider contracts
  • Meet Department Quality and Accuracy Standards.
  • Interfaces with other departments to obtain necessary information required for resolution of claims
  • Advise management of any claim issues or inappropriate and/or incorrect billing
  • Other duties assigned by management

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:
  • An education level of at least a high school diploma or GED
  • 1+ years' experience as a Medical Claims Examiner working on "Professional" claims (Billing of claims is not considered)
  • Solid experience with ICD9/10
  • Knowledge of DOFR and Provider contract interpretation
  • Proficient experience with Word and Excel

Preferred Qualifications:
  • Ability to multi-task, this includes ability to understand multiple products and multiple levels of benefits within each product
  • Prior Medicare, HMO experience preferred
  • Working knowledge of Medical Terminology and CPT4
  • Excellent Data Entry skills preferred

Making claims a positive experience for our members can drive your sense of impact and purpose. Join us as we improve the lives of millions. Learn more about how you can start doing your life's best work.(sm)

North American Medical Management, California, Inc. (NAMM) develops and manages clinician networks, offering a full range of services to assist physicians and other clinicians in their managed care and business operations. For over 17 years, NAMM has been an innovator in health care with a track record for quality, financial stability, extraordinary services and superior electronic capabilities. Prime Care Medical Network is a key affiliate.

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare's support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: Medical or Healthcare Claims examiner, Medicare, HMO, provider, ICD9, ICD10, DOFR, CPT Coding, Ontario, CA, California

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