As a healthcare organization dedicated to providing quality services to the Central Coast community, our client is seeking a detail-oriented and highly motivated individual to join their team. The ideal candidate will be committed to supporting the health and well-being of members of the community and will bring strong claims expertise, accuracy, and accountability to the role.

The Medical Claims Examiner is responsible for researching, reviewing, correcting, and responding to D-SNP pended claims, as well as reviewing audit reports in a timely manner. This role determines claim payment eligibility in accordance with internal policies, procedures, and regulatory guidelines, while maintaining accurate documentation related to medical procedures, CPT, HCFA, and coding requirements.

Key Responsibilities:

• Ensure adherence to regulatory and internal guidelines in conjunction with company policies and procedures related to D-SNP claims processing
• Review, price, and release assigned medical claims, including paper and electronic submissions
• Research, correct, and respond to all D-SNP pended claims in a timely manner
• Review manual review reports that suspend D-SNP claims for further evaluation
• Determine claim payment eligibility in accordance with established policies and procedures
• Maintain accurate documentation and correspondence related to medical procedures, CPT, HCFA, and coding requirements
• Monitor audit reports and address identified issues within required timeframes
• Maintain a daily activity log to track productivity and workflow
• Assist with general claims processing activities as needed
• Stay current on D-SNP policies, regulatory changes, and claims processing requirements
• Contribute to departmental improvement initiatives and special projects as assigned
• Participate in internal meetings and maintain compliance with all organizational policies and procedures

Qualifications:

• Strong knowledge of the Medicare D-SNP program and dual-eligible claims processing (Medi-Cal and Medicare D-SNP)
• Hands-on experience with the QNXT claims processing system
• Prior experience in a high-volume claims production environment
• Working knowledge of medical terminology and healthcare coding standards
• Strong attention to detail with the ability to accurately review and process claims
• Effective oral and written communication skills
• Ability to manage multiple priorities and meet productivity and quality standards
• Medical terminology and/or coding experience highly desirable

Education and Experience:

• High school diploma or equivalent required
• Minimum of three (3) years of experience as a Medical Claims Examiner

Compensation:

• Hourly Rate: $23.30 – $32.62 per hour