Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
The Claims Examiner III is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes: Distribution of work to Claims team based on type of claim and skill set of Claims Examiners. Work in conjunction with Trainer to cross train and enhance skills of existing Claims Examiners. Conducts the quality assurance function for the department in concert with the Claims Quality Specialist. Serve as a back-up Supervisor and resource to other claims examiners. Assists claims examiners with the most difficult cases and caseload issues. Serves as peer mentor and provides resource information to other claims examiners. Acts as a resource for management and staff, provides technical support within area of responsibility; use logic to analyze or identify underlying principles, reasons, or facts associated with information or data to draw conclusions. Monitor the processing and inventory of claims to ensure inventory is balanced and processed within regulatory compliance, take corrective actions as necessary to mitigate issues. Working closely with Claims Examiners on reviewing claims for required information, verifying authorizations, pending when necessary, maintaining follow-up, updating and releasing pended claims when necessary.Duties
Conduct the quality review of processed claims; Complete high dollar claim review/audit; Resolve difficult cases and caseload issues; Resolve complex, severe exposure claims; Determining correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions; Working with Claims team to ensure the processing all claims eligible or ineligible for payment accurately and conforming to quality, production, and timeliness standards; Negotiate reimbursement amounts for out-of-network claims; Identify dual coverage, potential third party savings/recovery, and process claims accordingly; Maintaining department databases used for report production and tracking ongoing work. Review and inspect work for quality, accuracy and completeness. Includes standard claims, high dollar claims, and specific audit reports. Analyze, summarize and review claims data, report findings, interpret results and make recommendations for improvement.
Ensure Claims will be processed within the contractual and/or regulatory time frames as supported by the departmental policies. Review workflows for efficiency, identify obstacles/impediments and redesigns to speed processing and increase efficiency. (30%)
Resolve provider claims payment disputes. Act as resource for the less experienced staff and handle most difficult cases. Researching any missing information or required information. Respond by telephone or in writing to providers, members, or other internal departments to process and resolve the claim issue. Process all provider payment disputes to ensure compliance with departmental and company policies and procedures. Track resolution of issues assigned to delegated partners and/or their subcontractors for contract and regulatory compliance. Provide resolution, recommendation and documentation of the Claims and Provider Dispute Resolution process. Deal with people in a manner with sensitivity, tact and professionalism. Assesse member/provider needs. Develop and implement plans and changes to meet those needs. Resolve all issues within the specific time frame as supported by departmental policies. (25%)Education Required Associate's Degree In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Bachelor's Degree Experience
At least 0-2 years of healthcare claims processing experience in a managed care environment.
Has excellent experience in handling complicated claims cases.
Previous Medi-Cal claims processing experience and knowledge of State.
Ability to operate PC-based software programs or automated database management systems.
Strong communication skills with excellent analytical and problem- solving skills.
Ability to self-manage in a fast-paced, detail-oriented environment.
Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials (PDR, CPT, ICD-10, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge.
Moderate knowledge of Microsoft Word and Excel.
Department of Health Services regulations.
Knowledge of Medicare claims processing.Licenses/Certifications Required Licenses/Certifications Preferred Required Training Additional Information
L.A. Care offers a wide range of benefits including
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
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