Senior Medical Claims Examiner/Auditor

Insight Global
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Job Details

  • Location: Los Angeles, CA, 90036
  • Date Posted: 2024-02-19
  • Employment Type: Full Time
  • Category: Accounting
  • Req Number: 339931
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Description

A client in the Los Angeles, CA area is looking for a full time Senior Medical Claims Examiner to work onsite in their Hollywood office. The position interfaces with department management, department employees, and employees from other departments. The position also requires contact with participants and their families, business managers, other insurance companies, and healthcare providers (e. g. doctors and hospitals).
ESSENTIAL FUNCTIONS
Audit high dollar claims, $3,500 and over, on a prospective and/or retrospective basis.
Identify root causes and associated error trends to determine appropriate training needs and suggest modifications to policies and procedures.
Use professional concepts & company policies & procedures to solve a wide range of difficult problems in imaginative & practical ways.
Perform follow-up on the status of outstanding internal audit issues.
Work on special projects for the manager and the assistant manager.
Review and analyze Anthems reports for updates and adjustments.
Review internal reports for audit claims selection. Assist examiners with questions pertaining to audits.
Provide training to staff as assigned.
Recommend process improvements. Provide feedback on issues/suggestions regarding filters/edits
Test for new filter development and implementations as assigned.
Participate in meetings with participants and other departments.
Write letters to participants and providers requesting additional information when necessary.
Regular, predictable, and reliable attendance is required.
Ability to accept direction and developmental guidance from supervisor.
Ability to work effectively with individuals at all levels.

We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal. com.

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Extensive knowledge of medical terminology, ICDA9, CPT codes.
Extensive knowledge of Plan benefits, group insurance, and Medicare principals.
Knowledge of Coordination of Benefits rules.
Considerable knowledge of basic math.
Ability to maintain production standards in a detail-oriented, quality-conscious service environment.
Ability to work independently with minimal supervision.
Strong analytical abilities.
Good written and verbal communication skills.
Good typing skills and the ability to operate ten-key calculator.