SUMMARY OF POSITION:
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 Manager with MSO management reports,
and other special projects as needed.
ESSENTIAL JOB FUNCTIONS:
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.
processing errors and make corrections prior to the weekly FFS payment cycle.
repayment or deduction per Physician and/or Vendor Contract terms.
disputes according to AB1455 requirement and report status to health plan(s).
payment status and handle member billed issues when arise.
annual delegation oversight audit(s) performed by Health Plan(s).
to meet turn-around-time and/or CMS/DHCS/MCP regulatory requirement.
activities, and other MSO staff with general claims information.
department manager and MSO System Configuration team to correct/resolve them.
efficiencies and results.
or co-worker as appropriate.
QUALIFICATIONS:
relevant work experience in healthcare medical claims processing and examination field.
adjudication, and auditing.
billing in Medi-Cal and Medicare Advantage program required.
AB1455, and ICE standards), particularly DHCS/Medi-Cal and CMS/Medicare
guidelines required.
ICD, POS, and claim forms.
systems preferred.
LANGUAGE:
STATUS:
This is an FLSA NON-exempt position.
This is not an OSHA high-risk position.
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