Purpose Statement / Position Summary The Claim Adjuster is responsible for determining if an internal or external request for payment/denial reconsideration is accurate, appropriate and meets all regulatory requirements and health plan guidelines.
Process all adjustments based on departmental standards, regulatory requirements and health plan guidelines.
Consistently meet the timeliness standards set forth by CMS, DMHC, health plans and departmental standards.
Determine and appropriately apply level of reimbursement based on established criteria; contracts, HMO contracts, reciprocity, etc.
Understand and interpret provider contracts and health plan Division of Financial Responsibility (DOFR).
Develop and maintain effective business relationships with internal and external clients.
Correspond with providers and inter-office departments to process and resolve adjustment requests.
Effectively handle special projects and member reimbursements within established departmental guidelines.
Produce and review weekly inventory reports on all pending adjustment requests and provide report to management.
Process all provider dispute resolution (PDR) requests based on CMS, DMHC requirements, health plan guidelines and departmental standards.
Perform check voids and full/partial refunds based on department standards.
Conduct error trend analyses.
Computer literacy on PC based software programs, including Microsoft Excel, Access & Word.
Understand AB1455 regulations including process and requirements of provider dispute resolution (PDR).
Minimum of 5 years Managed Care claims processing experience in an IPA, Medical Group or Health Plan setting.
Understand and interpret Health Plan Division of Financial Responsibility (DOFR).
Comprehensive knowledge of ICD-9, CPT, and HCPCS codes, medical terminology, and COB.
Comprehensive knowledge of various fee schedules, including, but not limited to DRG, APC, ASC, RBRVS.
Strong analytical, mathematical and problem solving skills.
Demonstrate effective communication, interpersonal, and organizational skills.