The Position: Under the supervision of the Supervisor, Claims and Provider Relations, the Senior Claims Examiner researches and adjudicates basic and moderately complex claims, determines eligibility and generates appropriate correspondence.

DUTIES AND RESPONSIBILITIES:

• Under limited supervision, reviews, researches and adjudicates basic and moderately complex claims based on department policies and procedures
• Applies interpretive rules associated with contracts in claims processing systems, processes adjustments, and reviews appropriate assignment of fee.
• Applies manual pricing for hospital inpatient, SNF, and Hospice claims
• Enters and process refunds in EZCAP
• Processes invoices to generate EPF file as needed for EDI upload
• Creates payment batch(es) for check run
• Reviews and researches, as necessary, claims and eligibility inquiries, payment disputes, denial upholds, including adjustments of claims if applicable
• Generates appropriate correspondence based on established policies and procedures
• Communicates and collaborates with providers, clients and CEI staff as job responsibilities require, or as directed
• Must have the ability to recognize trends and inconsistencies in claims billing and take proactive measures for correction
• Must have working knowledge of the CMS web site, Medi-Cal, Denti-Cal and Medicare Contractor web sites
• Maintains the confidentiality of all company procedures, results and information about participants or families
• Follows all CEI Policies and Procedures
• Exhibits regular and predictable attendance and punctuality
• Adheres to standards from professional conduct and dress code
• Complies with all agency training requirements
• Maintains safe working environment by following CEI’s safety P&P’s
• Maintains a courteous, helpful and professional attitude on the job. Displays a willingness and ability to be responsive to all customer groups
• Performs other duties as assigned in a positive and helpful manner

QUALIFICATIONS:

• The candidate must have comprehensive knowledge of medical terminology, CPT, ICD10-CM, HCPCS or necessary codes required for the accurate payment of claims
• A minimum of 3 years claims experience in a Medicare/Medi-Cal environment is required
• Intermediate knowledge of computer skills preferred: MS Outlook, Excel and Word
• Ability to work effectively in a multi-disciplinary environment
• High School Diploma/GED required and Bachelor’s preferred

The above job description is intended to communicate the general function of the mentioned position and by no means shall be considered an exhaustive or complete outline of the specific tasks and functions that will be required. CEI reserves the right to change job descriptions, site assignments, and or work hours as required by the needs of the program. All employees are expected to perform their duties within their ability as required by the job and/or as requested by management.