Claims Examiner II
at Ronin Staffing

Date Posted: 8/9/2020

Job Description

: Claims Examiner II 
Pay: DOE
Location: Monterey Park, CA 91755
Duration: 4 month contract + possible extension
Schedule: 8-5

Job Description:

A Claims Examiner is responsible for analyzing and the adjudication of medical claims as it relates to managed care. Performs payment reconciliations and/or adjustments related to retroactive contract rate and fee schedule changes.

Skills and Abilities:

  • Intermediate to advanced word processing, spreadsheet, presentation, and internet skills.
  • Moderate to Expert-level working knowledge of complex billing and documentation regulations, with the ability to research additional topics when necessary.
  • Proficient knowledge of the reading of a CMS-1500 and UB-04 form.
  • Read, interpret and summarize medical contracts/division responsibility before allowance of payments.
  • Fundamental understanding of managed care as it relates to Medi-Cal, Medicare, and Commercial Lines of Business.
  • Fundamental understanding of Health Plan, State, and Federal regulations.
  • Able to read and interpret Fee schedules, specifically Medi-Cal and Medicare.
  • Strong analytical, detail-oriented skills with a firm understanding of healthcare operational processes and technology concepts.
  • Ability to maintain the highest standards of confidentiality and to work with a high degree of integrity to perform objective and constructive audits.
  • Highly motivated with great organizational skills and the ability to multitask, handling interruptions and achieving deadlines.
  • Ability to perform services in a variety of work settings while maintaining a high degree of customer service.
  • Demonstrates a results-oriented approach for delivering service in an accurate, complete, and timely fashion.
  • Demonstrate success working both individually and with a team in a fast-paced, high volume, deadline oriented environment with emphasis on accuracy and timeliness.
  • Excellent communication skills, both oral and written, in order to deal effectively with a variety of interpersonal relationships and situations.
  • Ability to follow up on pending issues and meet deadlines.
  • Ability to cultivate strong working relationships with personnel from various areas of responsibility within the organization and interact with employees, customers and vendors in a professional manner.
  • Must be able to follow directions and perform independently according to departmental standards when no directions are given.
  • Must be able to willingly accept responsibility and possess the desire to learn new tasks.
  • Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.

Essential Job Functions of Job Description

  • Process medial claims, professional and institutional as it relates to the appropriate Federal and State regulations based on the member’s Line of Business; Medicare, Medi-Cal, Commercial, PACE Lines of Business.
  • Read and interpret DOFRs as it relates to the claim in order to ensure that group is financially at risk for payment.
  • Read and interpret provider contracts to ensure payment/denial accuracy.
  • Read and interpret Medi-Cal and Medicare Fee Schedules.
  • Correct claims payment/denial errors identified by the Claims Auditor prior to a check run.
  • Must maintain an error accuracy of under 3%.
  • Communicate with Claims Management for any issues relating to provider, fee schedule, eligibility, authorization, or system issues.
  • Assist in the creation of any business rules and training in order for the Claims Department to become more efficient and accurate.
  • Coordinate with the Recovery Department for any identified overpayments.
  • Attend monthly departmental meetings and provide feedback when requested.
  • Other duties as assigned.

Required/Desired Skills:

  • 3+ years of Claims Processing experience in a managed care environment. – Required
  • Must be knowledgeable of Medi-cal regulations. – Required
  • Must have an understanding to read and interpret DOFRs and Contracts – Required
  • Must have an understanding how to read a CMS-1500 and UB-04 form – Required

Job Snapshot

  • Employee Type: Contractor
  • Location: Monterey Park, CA
  • Job Type: Other
  • Experience: Not Specified
  • Date Posted: 8/9/2020

About Us

Founded in 1999 as a woman- and minority-owned IT staffing organization, Ronin Staffing has grown into a full-service staffing search firm that recruits and places qualified and quality candidates with expertise in a wide range of areas, including Engineering, Aerospace, Administration, Accounting/Financing, to name a few. We offer contract-only, contract-to-hire or direct-hire services to our clients and our contractors alike.

Our team of experienced, dynamic and tenacious recruiting specialists will provide you with the personal assistance you need to keep your career moving onward and upward. Whether you are looking for hourly, mid-management or executive level positions, you can be confident in our recruiters’ ability to match you with just the right assignments with just the right companies to suit your needs. Many members of our staff have backgrounds in the industries for which they now recruit, and Ronin has become one of the leaders in providing professionals to Fortune 100, 500, and 1000 companies.

We are proud to offer you a full line of services to help you to meet your career objectives, including resume assistance, human resources consulting, and expert guidance on professional interviewing techniques. We also offer direct deposit and a competitive benefits package.

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