Healthcare Claims Examiners, Adjusters & Auditors (REMOTE)

Healthcare Claims Examiners, Adjusters & Auditors (REMOTE)

• Job Details

1. Posting Date: 01-17-25
2. Reference ID: 238404
3. Location: Woodland Hills, CA
4. Work Location: Remote
5. Discipline: Healthcare Insurance
6. Job Type: Direct Hire
7. Salary Expectations/ Pay Rate or Range: $22.00-$27.00 per hour, $41,600-56,160 annual salary (based on experience & position)

• Job Description

1. Responsibilities/ Job Duties:

Claims Examiners/Adjustors - (10 openings)

• The claims examiner is responsible for the adjudication of claims, in accordance with outside regulations and the contractual obligations of the Health Plans and/or the IPAs.
• Researches, reviews and contacts provider services for problem claims and issues, as needed.
• Accurately review all incoming Provider claims to verify necessary information is available.
• Meets production standards of 100-150 claims as established by claims management
• Adjudicate claims in accordance with departmental policies and procedures and other rules applicable to specialty claims.
• Work with Medi-Care, Medicare and Commercial claims.

Claims Auditor - (2 openings)

• A Claims Auditor is responsible for the overall quality of claims processes as well as compliance, in accordance with outside regulations and the contractual obligations of the Health Plans and/or the IPAs.
• Research, reviews and contacts provider services for problem claims and issues, as needed.
• Suggests process improvements to management and is a resource of information to all staff.
• Performs special projects and helps department manager and director as needed.
• Review and audit the examiner claims providing feedback and accuracy.

• Minimum Education and Experience Qualification Requirements:

Claims Examiners/Adjustors -

• 1+ year HEALTHCARE claims examining experience (truly examining, processing doesn't apply).
• Must be experienced adjudicating claims - California required but can live anywhere!
• Must have worked in a managed care setting doing medical claims (healthplan or MSO) - workers comp, dental, etc doesn't work .
• To qualify for the adjuster position, must have more diverse experience working with (ambulance, ER, hospital, DME) claims.

Claims Auditor -

• Must have extensive experience adjudicating claims.
• Must have experience with California Claims but can live anywhere!
• Experts and reading contracts, eye testing claims audits and review,
• Audit claims before the payment goes out
• They are communicating and giving feedback back to the examiners regarding errors - feedback need to be effective and constructive
• Able to do root cause analysis.

Schedule/ Shift: Can start shift between 6am-9am and end shift 3pm-6pm

• Benefits:

• PTO (Paid Time Off): Based on employee tenure, ranges from 15-25 days off per year.

• Holiday Pay: Receive holiday pay for all federal holidays after completing 90th day of employment; 7 paid federal holidays, 3 additional floating holidays.

• Health Benefits / Dental / Vision: Great low-cost group rates for employees! 100% company group paid employee premiums for HMO plan.

• 401k: Competitive company match of the employee's salary.

• Life & Supplemental Insurance

• Employee Assistance Program (EAP)

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.

Medix is acting as an Employment Agency in relation to this vacancy.