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.
Responsibilities
- Be familiar and comply with all company policies and procedures
- Effectively manages a caseload of 50-150 claims a day
- Initiates and conducts claim investigation in a timely manner
- Achieve claims processing standards for accurate and timely claims adjudication
- Maintain claims processing standards to meet performance appraisal goals
- Determines compensability of claims and administer benefits, based upon product benefits and CMS guidelines
- Manages medical treatment and medical billing, authorizing as appropriate, with requests for surgical treatment to be referred to supervisor prior to authorizing
- Communicates with provider regarding claims issues
- Computes and processes payment
- Finalizes all claims and obtains authority as designated
- Maintains documentation in file to reflect the status of and work being performed on the file
- Communicates appropriate information promptly to the client to resolve claims efficiently
- Involves supervisory staff when appropriate
- Adheres to all Company policies and procedures
- Participates in audits and file reviews, as needed
- Performs other duties as assigned to include but not limited to assisting Document Processing Associate
- Other duties as assigned, mailroom tasks
Skills
- Associate degree
- One (1) year related experience; or equivalent combination of education and experience
- Technical knowledge of statutory regulations and medical terminology
- Familiar with CMS claims payment, billing guidance
- Knowledge of CPT, HCPCS and ICD-10 diagnosis codes
- Strong analytical skills, including the ability to analyze and organize data
- Strong attention to detail
- Excellent organizational, oral presentation and written and verbal communication skills
- Proficiency in MS Office products, including PowerPoint, Excel, and Word
- Must be able to travel when needed or required
- Ability 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) lbs
- Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly
- Bachelor's degree in related field preferred
Company Overview
Clever 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.