Claims Examiner III – Medi-Cal Managed Care

This is a fully remote position, open to applicants in California.

📋 Description

• Process, adjust, and adjudicate professional, institutional, and complex claims, with a focus on Medi-Cal Managed Care claims.

• Act as a subject matter expert in Medi-Cal claims processing, reimbursement methodologies, delegated risk arrangements, and regulatory requirements.

• Review and implement provider contracts, benefit plans, divisions of financial responsibility, authorizations, and reimbursement methodologies for precise adjudication.

• Validate diagnosis and procedure codes while ensuring adherence to DHCS, DMHC, CMS, AB 1455, AB 1324, and other relevant regulations.

• Investigate, analyze, and resolve intricate claims issues, payment discrepancies, provider disputes, grievances, escalations, and processing errors.

• Process claim adjustments, voids, reopenings, reconsiderations, overpayment recoveries, and underpayment corrections.

• Generate and document communications with providers and necessary letters.

• Collaborate with Customer Service, Provider Relations, Configuration, Compliance, and other departments.

• Create and utilize Crystal and SQL reports for inventory management, operational efficiency, and compliance with regulatory turnaround times.

• Identify payment errors, configuration issues, and opportunities for process improvements; recommend corrective actions.

• Participate in audits, regulatory reviews, workflow enhancement initiatives, and special projects.

• Meet productivity and quality standards while ensuring accurate documentation in EZ-Cap and related systems.

• Assist with training, mentoring, check run preparation, and other departmental needs as assigned.

• Adhere to company policies, procedures, and confidentiality requirements.

⛳️ Requirements

• Over 10 years of experience in claims adjudication, particularly in processing Medi-Cal managed care claims.

• At least 5 years of experience in processing Medicare and Commercial claims.

• Proficiency in using EZ-Cap is required.

• In-depth knowledge of California Medi-Cal, Medicare, and Commercial reimbursement methodologies.

• Comprehensive understanding of DHCS, DMHC, CMS, and applicable state and federal claims regulations.

• Experience with delegated IPA, Medical Group, and capitated provider arrangements.

• Proven experience in resolving Provider Disputes (PDRs), claims appeals, grievances, and escalated claims issues.

• Strong knowledge of AB 1455 Claims Settlement Practices.

• Strong knowledge of AB 1324 Requirements.

• Strong knowledge of Knox-Keene regulations.

• Strong knowledge of timely filing requirements.

• Strong knowledge of Coordination of Benefits (COB).

• Strong knowledge of claims payment and regulatory turnaround requirements.

• Familiarity with CPT, HCPCS, ICD-10, DRG, APC, ASC, and other reimbursement methodologies.

• Proficient in outpatient PPS, inpatient DRG, interim rate payment methodologies, and other reimbursement structures relevant to Medi-Cal, Medicare, and Commercial products.

• Strong analytical, problem-solving, and claims research skills.

🏝️ Benefits

• 100% employer-paid medical, vision, dental, and life insurance coverage.

• Paid holidays, sick time, and vacation time.

• 401k plan.

• Additional employee-paid coverage options.

• Fully remote work environment.

• Flexible work environment and schedules.