Claims Examiner

At WelbeHealth, we are transforming the reality of senior care by providing an all-inclusive healthcare option to the most vulnerable senior population, while serving as a care provider and care plan to those individuals we serve.

Our Health Plan Services team helps ensure excellent care delivery for our participants, and the Claims Examiner plays a pivotal role in ensuring timely and efficient processing of claims for our contracted specialty provider partners.

Essential Job Duties:

• Examine, review and process claims according to contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
• Assess appropriateness of returned, denied, or paid claims by reviewing and following contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
• Ensure claim timeliness processing standards are being met
• Work alongside manager to establish and maintain claims processing rules that meet all regulatory and business requirements
• Assist internal and external partners with questions related to claims decisions or claims statuses
• Maintain a comprehensive understanding of claim processing guidelines at both the federal and state level

Job Requirements:

• High School Diploma or Equivalency, professional experience may be substituted
• Minimum of three (3) years of experience with processing, researching, and adjudicating claims in a complex managed care environment
• Working knowledge of the health plan insurance industry and CPT/HCPCS procedure codes, and relevant federal and state regulations
• Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee schedule, Diagnosis Related Groups (DRG), Multiple Procedure Payment Reduction (MPPR) and benefit interpretation and administration
• In depth experience with Medicare and Medicaid claims processing
• Demonstrated skills within Microsoft Office Applications & electronic claims processing systems
• Strong organizational, analytical, communication, and time management skills

Benefits of Working at WelbeHealth: Apply your claims expertise in meaningful ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for.

• Medical insurance coverage (Medical, Dental, Vision)
• Work/life balance – we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, sick time
• Advancement opportunities - We’ve got a track record of hiring and promoting from within, meaning you can create your own path!
• And additional benefits