Sr. Claims Examiner *Hybrid*

Claims San Francisco, California


Description

Job Title: Senior Claims Examiner
Department: Operations - Claims

About the Role:  
We are currently seeking a highly motivated Senior Claims Examiner. This role will report to the Manager - Claims and enable us to continue to scale in the healthcare industry. 

What You'll Do: 
  • Maintain current knowledge of all ICD-9, CPT, and HCPC codes 
  • Proficient with Federal and State requirements to identify areas of deficiency in Claims processing 
  • Apply knowledge of general billing for health care providers and institutions 
  • Proficient understanding of AB1455 Claims Settlement Practice & dispute and resolution regulations 
  • Must be able to work independently and successfully with limited supervision 
  • Knowledge of rate application for all outpatient and inpatient facility, ASC, APR-DRG, DRG, interim rate and CMAC rates of payment methods to appropriated line of business (Medicare, Commercial, Medi-Cal) 
  • Ability to identify incorrect billing, coding, NCCI edits, duplicate payments, and incorrect payment adjudication 
  • Proficient in applying Health Plan Benefit Matrices, Division of Financial Responsibility 
  • Ability to conduct internal mock audits prior to Health Plan onsite visits 
  • Work efficiently with Health Plans to ensure all IPA clients pass audits 
  • Must be able to communicate with Health Plan Auditors regarding any type of findings 
  • Write and review Corrective Action Plans (CAP) issue by Health Plans 
  • Ability to prepare, test, and evaluate P&P’s for Claims Operations 
  • Design workflow to support the betterment of Claims Production and Claims Audits 
  • Maintains the strictest confidentiality at all times 
Qualifications: 
  • Associate degree or bachelor's degree from a college or university, or 
  • Minimum of 3 years' experience working in the healthcare industry or medical claims operations 
  • EZ-CAP knowledge is preferred 
  • Proficient in using MS Office 
  • Typing speed 50+ WPM and knowledge of 10 key desired 
Who We Are: 
  
Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient. 
  
Our platform currently empowers over 10,000 physicians to provide care for over 1 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system. 
  
Our Values: 
  • Put Patients First 
  • Empower Entrepreneurial Provider and Care Teams 
  • Operate with Integrity & Excellence 
  • Be Innovative 
  • Work As One Team 
  
Environmental Job Requirements and Working Conditions: 
  • Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 823 Jackson Street., San Francisco, CA 94133.
  • The total compensation target pay range for this role is: $30.00 - $35.00 per hour. The salary range represents our national target range for this role. 
  
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. 
  
Additional Information: 
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.