St. Joseph Hospital

Are you looking for a position that will give you the flex time you need? How about an extra day off during the week? Well look no further! In our Claims Department we offer our employees a 4-10 shift as well as Tele-Commuting. If you have claims experience and are looking for a change, please apply now!

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There is currently an outstanding opportunity for you as a Claims Examiner III  in our Claims Department.

Working under the direction of the Claims Director, this position is responsible for consistently and accurately adjudicating all complex contracted professional capitated claims with fee-for-service carve outs, professional and hospital claims for non-contracted provider and contracted hospital claims for both Commercial and Senior plans within the timeliness and accuracy standards set forth by CMS, Department of Managed Care, AB1455 and the Claims Department policies and procedures.

Some of the Essential Functions:

• Must achieve and maintain 95% accuracy rate, 95% timeliness standard and 95% production requirement, utilizing departmental policy and as well as established procedures per Healthplan and Network.
• Should be able to recognize inappropriate CPT, ICD-9, HCPCS and Revenue codes. Accurately research member eligibility, duplicate claim submissions out of network services out of area services and COB - be able to adjudicate according to departmental procedures.
• Monitors and updates inventory reports in order to track claims in inventory and follows-up on all claims suspended for review purposes.

The preferred candidates will have the following experience and education:

• High School diploma or equivalent
• Minimum of 4 years of experience as a Claims Examiner in an IPA, Medical Group or Health Plan.
• Familiar with computerized claims processing/transaction system.
• Previous IDX experience is a plus!

We offer an Alternative Work Schedule for this position, which allows you to work 4 - 10 hour days per week to qualify for full-time status. Our benefits for full-time personnel include medical, dental, vision, life insurances, PTO, Paid holidays, 401(a) and 401(k) plans, credit union, and more!