Claims Examiner I - (NOT REMOTE)

Clever Care Health Plan is one of Southern California’s fastest-growing Medicare Advantage plans, dedicated to transforming the healthcare space. The Claims Examiner I will process non-complex claims, manage a caseload, and ensure accurate and timely claims adjudication while adhering to company policies.ResponsibilitiesBe familiar and comply with all company policies and proceduresEffectively manages a caseload of 50-150 claims a dayInitiates and conducts claim investigation in a timely mannerAchieve claims processing standards for accurate and timely claims adjudicationMaintain claims processing standards to meet performance appraisal goalsDetermines compensability of claims and administer benefits, based upon product benefits and CMS guidelinesManages medical treatment and medical billing, authorizing as appropriate, with requests for surgical treatment to be referred to supervisor prior to authorizingCommunicates with provider regarding claims issuesComputes and processes paymentFinalizes all claims and obtains authority as designatedMaintains documentation in file to reflect the status of and work being performed on the fileCommunicates appropriate information promptly to the client to resolve claims efficientlyInvolves supervisory staff when appropriateAdheres to all Company policies and proceduresParticipates in audits and file reviews, as neededPerforms other duties as assigned to include but not limited to assisting Document Processing AssociateOther duties as assigned, mailroom tasksSkillsAssociate degreeOne (1) year related experience; or equivalent combination of education and experienceTechnical knowledge of statutory regulations and medical terminologyFamiliar with CMS claims payment, billing guidanceKnowledge of CPT, HCPCS and ICD-10 diagnosis codesStrong analytical skills, including the ability to analyze and organize dataStrong attention to detailExcellent organizational, oral presentation and written and verbal communication skillsProficiency in MS Office products, including PowerPoint, Excel, and WordMust be able to travel when needed or requiredAbility to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbsAbility to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quicklyBachelor's degree in related field preferredCompany OverviewClever Care Health Plan is a healthcare company that provides health insurance for medicare services. It was founded in 2018, and is headquartered in Huntington Beach, California, USA, with a workforce of 201-500 employees. Its website is https://clevercarehealthplan.com.



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