Claims Examiner II - MSO

North East Medical Services
San Leandro, CA Full Time
POSTED ON 8/23/2022 CLOSED ON 3/6/2023

Job Posting for Claims Examiner II - MSO at North East Medical Services

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:

  • 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.

  • Assist the PDR Specialist in researching and resolving provider claims and payment

disputes according to AB1455 requirement and report status to health plan(s).

  • Respond to complex provider inquiries related to claims adjudication, denial, and

payment status and handle member billed issues when arise.

  • 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 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 CEO


QUALIFICATIONS:

  • Completion of a 2-year degree from an accredited University, may be substituted with

relevant work experience in healthcare medical claims processing and examination field.

  • Minimum four years’ experience in health insurance claims processing, examination,

adjudication, and auditing.

  • Strong knowledge of managed care and/or healthcare claim reimbursement or medical

billing in Medi-Cal and Medicare Advantage program required.

  • Working knowledge of State/Federal healthcare compliance requirements (HIPAA,

AB1455, and ICE standards), particularly DHCS/Medi-Cal and CMS/Medicare

guidelines required.

  • Working knowledge of medical terminology, standard code sets including CPT, HCPCS,

ICD, POS, and claim forms.

  • Strong English communication skills with strong analytical and problem solving skills.
  • Ability to self-manage in a detail oriented environment.
  • Ability to operate PC based software programs or automated database management

systems preferred.

  • Good organization and prioritization skills, outstanding in time management


LANGUAGE:


  • Must be able to fluently speak, read and write English.
  • Fluent in other languages are an asset.


STATUS:


This is an FLSA NON-exempt position.

This is not an OSHA high-risk position.

Liability Claims Examiner
AssuredPartners -
Oakland, CA
Claims Specialist II
Everest National Insurance Company -
Walnut Creek, CA
Claims Processor II / Job Req 654607627
Alameda Alliance -
Alameda, CA

Popular Search Topics

Salary.com Estimation for Claims Examiner II - MSO in San Leandro, CA
$71,064 to $92,090
If your compensation planning software is too rigid to deploy winning incentive strategies, it’s time to find an adaptable solution. Compensation Planning
View Core, Job Family, and Industry Job Skills and Competency Data for more than 15,000 Job Titles Skills Library

Sign up to receive alerts about other jobs with skills like those required for the Claims Examiner II - MSO.

Click the checkbox next to the jobs that you are interested in.

  • Claim Investigation Skill

    • Income Estimation: $49,870 - $61,915
    • Income Estimation: $50,835 - $63,780
  • Customer Support Skill

    • Income Estimation: $48,825 - $66,756
    • Income Estimation: $49,870 - $61,915
This job has expired.

Job openings at North East Medical Services

North East Medical Services
Hired Organization Address Daly, CA Full Time
The Director of Operations will provide the direction necessary to manage the day-to-day business operations of NEMS pri...
North East Medical Services
Hired Organization Address San Francisco, CA Full Time
The Diagnostic Medical Sonographer serves as a medical imaging professional providing clinically relevant information to...
North East Medical Services
Hired Organization Address Daly, CA Full Time
A Pharmacy Technician I will perform technical functions and related pharmacy duties at all pharmacies as well as activi...
North East Medical Services
Hired Organization Address San Francisco, CA Full Time
The Physician Assistant provides primary care to patients at NEMS, provides quality medical diagnostic services and trea...

Not the job you're looking for? Here are some other Claims Examiner II - MSO jobs in the San Leandro, CA area that may be a better fit.

Senior Claims Examiner - PLCA

AssuredPartners, Oakland, CA

Senior Claims Examiner

Berkley, Walnut Creek, CA