Claims Examiner (Managed Care) - Remote
Job Description
Grow your career at Cedars-Sinai!
Cedars-Sinai Medical Center has been named to the Honor Roll in U.S. News & World Report's "Best Hospitals 2024-2025" rankings. When you join our team, you'll gain access to our groundbreaking biomedical research facilities and sophisticated medical education programs. We offer learning programs, tuition reimbursement and performance-improvement projects so you can achieve certifications and degrees while gaining the knowledge and experience needed to advance your career.
We take pride in hiring the best, most hard-working employees. Our dedicated doctors, nurses and staff reflect the culturally and ethnically diverse community we serve. They are proof of our dedication to creating a dynamic, inclusive environment that fuels innovation and the gold standard of patient care we strive for.
What will you be doing:
The Claims Examiner is responsible for accurately and consistently adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy. Process claims according to all CMS and DMHC guidelines. Investigate and complete open or pended claims. Meet production and quality standards.
Responsible for productivity standards for number claims completed and for accuracy of entries.
Handles in a professional and confidential manner all correspondence.
Supports CSMNS core values, policies, and procedures.
Receives and adjudicates medical claims for processing; reviews scanned, EDI, or manual documents for pertinent data on claim for complete and accurate information.
Receives daily workflow via reports or work queue and incoming phone call.
Research claims for appropriate support documents.
Analyzes and adjusts data, determines appropriate codes, fees, and ensures timely filing and contract rates are applied.
Responds and documents resolution of inquiries from internal departments.
Assists Finance with researching provider information to resolve outstanding or stale dated check issues.
Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases.
Qualifications
Experience Requirements:
Three (3) plus years of medical claims processing for Medicare and Commercial products and provider dispute resolution processing in an IPA, HMO and Hospital related setting.
Three (3) plus years of experience with processing all types of specialty claims such as Chemotherapy, Dialysis, OB and drug and multiple surgery claims.
Preferred experience with automated claims processing system, Epic Tapestry.
Education Requirements:
High School Diploma/GED.
Bachelor's degree in Healthcare or related field of study, preferred.
About Us
Cedars-Sinai is a leader in providing high-quality healthcare encompassing primary care, specialized medicine and research. Since 1902, Cedars-Sinai has evolved to meet the needs of one of the most diverse regions in the nation, setting standards in quality and innovative patient care, research, teaching and community service. Today, Cedars- Sinai is known for its national leadership in transforming healthcare for the benefit of patients. Cedars-Sinai impacts the future of healthcare by developing new approaches to treatment and educating tomorrow's health professionals. Additionally, Cedars-Sinai demonstrates a commitment to the community through programs that improve the health of its most vulnerable residents.
About the Team
With a growing number of primary urgent and specialty care locations across Southern California, Cedars-Sinai's medical network serves people near where they live. Delivering coordinated, compassionate healthcare you can join our network of clinicians and physicians to improve the healthcare people throughout Los Angeles and beyond.
Apply Now
Grow your career at Cedars-Sinai!
Cedars-Sinai Medical Center has been named to the Honor Roll in U.S. News & World Report's "Best Hospitals 2024-2025" rankings. When you join our team, you'll gain access to our groundbreaking biomedical research facilities and sophisticated medical education programs. We offer learning programs, tuition reimbursement and performance-improvement projects so you can achieve certifications and degrees while gaining the knowledge and experience needed to advance your career.
We take pride in hiring the best, most hard-working employees. Our dedicated doctors, nurses and staff reflect the culturally and ethnically diverse community we serve. They are proof of our dedication to creating a dynamic, inclusive environment that fuels innovation and the gold standard of patient care we strive for.
What will you be doing:
The Claims Examiner is responsible for accurately and consistently adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy. Process claims according to all CMS and DMHC guidelines. Investigate and complete open or pended claims. Meet production and quality standards.
Responsible for productivity standards for number claims completed and for accuracy of entries.
Handles in a professional and confidential manner all correspondence.
Supports CSMNS core values, policies, and procedures.
Receives and adjudicates medical claims for processing; reviews scanned, EDI, or manual documents for pertinent data on claim for complete and accurate information.
Receives daily workflow via reports or work queue and incoming phone call.
Research claims for appropriate support documents.
Analyzes and adjusts data, determines appropriate codes, fees, and ensures timely filing and contract rates are applied.
Responds and documents resolution of inquiries from internal departments.
Assists Finance with researching provider information to resolve outstanding or stale dated check issues.
Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases.
Qualifications
Experience Requirements:
Three (3) plus years of medical claims processing for Medicare and Commercial products and provider dispute resolution processing in an IPA, HMO and Hospital related setting.
Three (3) plus years of experience with processing all types of specialty claims such as Chemotherapy, Dialysis, OB and drug and multiple surgery claims.
Preferred experience with automated claims processing system, Epic Tapestry.
Education Requirements:
High School Diploma/GED.
Bachelor's degree in Healthcare or related field of study, preferred.
About Us
Cedars-Sinai is a leader in providing high-quality healthcare encompassing primary care, specialized medicine and research. Since 1902, Cedars-Sinai has evolved to meet the needs of one of the most diverse regions in the nation, setting standards in quality and innovative patient care, research, teaching and community service. Today, Cedars- Sinai is known for its national leadership in transforming healthcare for the benefit of patients. Cedars-Sinai impacts the future of healthcare by developing new approaches to treatment and educating tomorrow's health professionals. Additionally, Cedars-Sinai demonstrates a commitment to the community through programs that improve the health of its most vulnerable residents.
About the Team
With a growing number of primary urgent and specialty care locations across Southern California, Cedars-Sinai's medical network serves people near where they live. Delivering coordinated, compassionate healthcare you can join our network of clinicians and physicians to improve the healthcare people throughout Los Angeles and beyond.
Apply Now