Claims Representative

Location: Remote (Required to attend onsite training in El Segundo, CA)
Hours: Monday - Friday, 6:00 AM - 2:30 PM

Job Summary:
We are seeking a detail-oriented and experienced Medical Claims Reviewer to join our team. The ideal candidate will be responsible for reviewing medical claims, ensuring compliance with regulatory standards, and working within various computer systems. This position requires strong analytical skills and the ability to manage multiple tasks simultaneously.

Key Responsibilities:

- Review medical claims submitted with and without prior authorization.
- Attach necessary medical records to claims to ensure completeness and accuracy.
- Engage with claims and clinical claims review teams to discuss trends identified during retrospective claims reviews.
- Provide insights and feedback to improve the claims review process.
- Review and re-direct inappropriate retro referral requests to the appropriate parties.
- Ensure that referral management is aligned with departmental standards.
- Comply with company and departmental standards for the timeliness of review and claims payment.
- Ensure consistency with regulatory standards related to claims turnaround time.
- Request medical records in a timely manner in accordance with regulatory and departmental compliance requirements.
- Maintain accurate records of all requests and follow-ups.
- Enter and update authorizations in the computer systems, including GE, IDX, and CURO.
- Ensure that all entries are accurate and up to date.

Qualifications:
- Strong knowledge of Microsoft Word, Excel, and Teams.
- Ability to work with multiple computer applications simultaneously.
- Attention to detail and strong organizational skills.
- Prior experience in medical claims review or a related field