Astrana Health
Claims Examiner II *Hybrid*
Astrana Health, Monterey, California, United States, 93941
Description
Job Title: Claims ExaminerDepartment: Operations - Claims
About the Role:
We are currently seeking a highly motivated 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:Performs through review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of servicesProcesses non-institutional claim types for all line of business (Medicare, Medical, Commercial, etc)The Specialist should clearly understand the products and healthcare benefits services offered to customers, including cost share, limits and regulatory rules and guidelinesConfigure provider contracts, Fee schedule updates and other documentsDevelop configuration testing & validate accuracy of data loadedCommunicated required system updates to Provider Contracting & Claims operationsCoordinate research & resolution of debarred & sanctioned providersCorrects system generated errors manually prior to final claims adjudicationCommunicated required system updates to Provider Contracting & Claims operationsProcess claims based upon the provider's contract/agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and NMM policies and proceduresAnalyzes and validates Medi-cal pricing researches, Adjusts and adjudicates claims reviews services for accurate charges and utilizes current billing code sets, (i.e International Classification Diseases (ICD 10) Codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as referenceValidates eligibility and other possible health insurance coverage on the claims (i.e Medicare primary, California Children services (CCS),,)Alerts manager or supervisor of more complex issues that ariseProcesses claim exception reports as assignedRecognize claim correspondences from multiple IPAsRecognize the health plan financial risk (Division of Financial Responsibility)Recognize the difference between Shared Risk and Full Risk claimsMaintain required levels of production and quality standards as established by managementAttendance at employer worksite is an essential job requirementWork assigned claim project to completionContribute to team effort by accomplishing related results as neededQualifications:
Strong understanding of claims lines of business (Medicare, Medical, Commercial, etc)Knowledge of MS Word, Excel and basic medical terminologyHigh School graduate or equivalentExcellent knowledge of CPT, HCPCS, ICD-10 CM, ICD-10 PCS, etcTyping speed 70+ WPM and knowledge of 10 key desiredAbility to multi-task and meet deadlinesStrong organization skills; ability to multitask and properly manage timePosition may require unscheduled overtime, week-end workAbility to understand work with proprietary software applicationsOrganizational ability and ability to exercise good judgmentWork independently as part of a teamAt least 2 year plus of claims processing experience in the health insurance industry or medical health care delivery systemYou're great for this role if:
Have EZ-CAP knowledgeWho 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 in order to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.
Our platform currently empowers over 12,000 physicians to provide care for over 1.3 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 in order to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.
Our Values:
Put Patients FirstEmpower Entrepreneurial Provider and Care TeamsOperate with Integrity and ExcellenceBe InnovativeWork as One TeamEnvironmental 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 1600 Corporate Center Dr, Monterey Park, CA 91754The total compensation target pay range for this role is $24.00 - $26.00 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 [email protected] 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.
Job Title: Claims ExaminerDepartment: Operations - Claims
About the Role:
We are currently seeking a highly motivated 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:Performs through review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of servicesProcesses non-institutional claim types for all line of business (Medicare, Medical, Commercial, etc)The Specialist should clearly understand the products and healthcare benefits services offered to customers, including cost share, limits and regulatory rules and guidelinesConfigure provider contracts, Fee schedule updates and other documentsDevelop configuration testing & validate accuracy of data loadedCommunicated required system updates to Provider Contracting & Claims operationsCoordinate research & resolution of debarred & sanctioned providersCorrects system generated errors manually prior to final claims adjudicationCommunicated required system updates to Provider Contracting & Claims operationsProcess claims based upon the provider's contract/agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and NMM policies and proceduresAnalyzes and validates Medi-cal pricing researches, Adjusts and adjudicates claims reviews services for accurate charges and utilizes current billing code sets, (i.e International Classification Diseases (ICD 10) Codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as referenceValidates eligibility and other possible health insurance coverage on the claims (i.e Medicare primary, California Children services (CCS),,)Alerts manager or supervisor of more complex issues that ariseProcesses claim exception reports as assignedRecognize claim correspondences from multiple IPAsRecognize the health plan financial risk (Division of Financial Responsibility)Recognize the difference between Shared Risk and Full Risk claimsMaintain required levels of production and quality standards as established by managementAttendance at employer worksite is an essential job requirementWork assigned claim project to completionContribute to team effort by accomplishing related results as neededQualifications:
Strong understanding of claims lines of business (Medicare, Medical, Commercial, etc)Knowledge of MS Word, Excel and basic medical terminologyHigh School graduate or equivalentExcellent knowledge of CPT, HCPCS, ICD-10 CM, ICD-10 PCS, etcTyping speed 70+ WPM and knowledge of 10 key desiredAbility to multi-task and meet deadlinesStrong organization skills; ability to multitask and properly manage timePosition may require unscheduled overtime, week-end workAbility to understand work with proprietary software applicationsOrganizational ability and ability to exercise good judgmentWork independently as part of a teamAt least 2 year plus of claims processing experience in the health insurance industry or medical health care delivery systemYou're great for this role if:
Have EZ-CAP knowledgeWho 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 in order to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.
Our platform currently empowers over 12,000 physicians to provide care for over 1.3 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 in order to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.
Our Values:
Put Patients FirstEmpower Entrepreneurial Provider and Care TeamsOperate with Integrity and ExcellenceBe InnovativeWork as One TeamEnvironmental 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 1600 Corporate Center Dr, Monterey Park, CA 91754The total compensation target pay range for this role is $24.00 - $26.00 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 [email protected] 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.