BusinessOperations - Claims Examiner (Operations) 1 - 700092

Impact and Purpose Candidate Requirements Education/Certification Required: High school diploma or higher education Preferred: High school diploma or higher education Licensure Required: No License Required Preferred: CA Pharmacy Technician License Years of experience required. Projected HM Candidate Review Date: 1-2 days post shortlisting Number and Type of Interviews: 1 Interview (Panel of 3) Extra Interview Prep for Candidate: No Required Testing or Assessment (by Vendor): Manager Communication Preferences & Next Steps

Position Purpose: Under close supervision, this position processes routine claims within a single product line to determine type and amount of benefit payable. Performs limited duties, subject to review and approval, for the processing of such claims assigned, consistent with applicable policies, procedures and department guidelines.

Education/Experience: High School diploma or equivalent required. Minimum six months claims examining experience or completion of a technical class specializing in claims processing required. Experience working with Microsoft applications is preferred.


" Determines level of reimbursement based on established criteria, provider contract, plan and employer group provisions.
" Processes all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specification.
" Matches authorizations to claims, maintains current desk procedural and reference materials.
" Reviews appeals and complaints; researches any missing or required information.
" Responds by telephone or in writing to providers, members, or other company departments to process and resolve the claim issue.

EEO:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

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Position Purpose: Under close supervision, this position processes routine claims within a single product line to determine type and amount of benefit payable. Performs limited duties, subject to review and approval, for the processing of such claims assigned, consistent with applicable policies, procedures and department guidelines. Education/Experience: High School diploma or equivalent required. Minimum six months claims examining experience or completion of a technical class specializing in claims processing required. Experience working with Microsoft applications is preferred. " Determines level of reimbursement based on established criteria, provider contract, plan and employer group provisions. " Processes all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specification. " Matches authorizations to claims, maintains current desk procedural and reference materials. " Reviews appeals and complaints; researches any missing or required information. " Responds by telephone or in writing to providers, members, or other company departments to process and resolve the claim issue.
Story Behind the Need Business Group & Key Projects
Health plan or business unit Team culture Surrounding team & key projects Purpose of this team Reason for the request Motivators for this need Any additional upcoming hiring needs?		Pharmacy Operations Department (Centene Pharmacy Services) Inclusive Culture Pharmacy Accumulator Audits and Benefits Our team supports the Health Plan Need support for SB368 Bill and AB1184 and support for Accumulator Audits and Pharmacy Claims One of our full-time employees recently left our department, so we are short staffed
Typical Day in the Role
Daily schedule & OT expectations Typical task breakdown and rhythm Interaction level with team Work environment description		Handle Combined Pharmacy/Medical Accumulator Review Pharmacy Claims Review (Coordination of Benefits, Dual Coverage, Foreign, Prior Insurance, Medicare Secondary Payor, Compounds, Copay Adjustments, Out of Network, Skilled Nursing/Custodial, Cruise Ship, Retroactive Prior Auth Requests, Out of Area Emergency, Third party (I.e. Medi-Cal), Veterans Administration, Universal Claim Forms, Verification of Rx Copay Card Usage for Brand medications Member Eligibility Updates ACD Phone Line Coverage for Exchange Members Call pharmacies to verify drug information and Rx copay card usage Review and audit Explanation of Benefits for multiple plans per SB368 Bill
Compelling Story & Candidate Value Proposition
What makes this role interesting? Points about team culture Competitive market comparison Unique selling points Value added or experience gained		Flexibility and Work Life Balance Compensation and Benefits Career Growth and Learning Inclusive Culture Impact and Purpose
Candidate Requirements
Education/Certification	Required: High school diploma or higher education			Preferred: High school diploma or higher education
Licensure	Required: No License Required			Preferred: CA Pharmacy Technician License
Years of experience required Disqualifiers Best vs. average Performance indicators		Must haves: Pharmacy or Medical claims processing experience Nice to haves: Pharmacy Tech or Medical Billing experience Disqualifiers: Performance indicators:
Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection		1	Pharmacy or Medical Claims Processing
		2	Phone Experience/Customer Service Experience
		3	Microsoft Word, Excel, Outlook
Candidate Review & Selection
Shortlisting process Second touchpoint for feedback Interview Information Onboard Process and Expectations		Projected HM Candidate Review Date:			1-2 days post shortlisting
		Number and Type of Interviews:			1 Interview (Panel of 3)
		Extra Interview Prep for Candidate:			No
		Required Testing or Assessment (by Vendor):
Manager Communication Preferences & Next Steps