Offer summary

Qualifications:

3-5 years of medical claims processing experience required., Knowledge of CMS claims coding and UB-04 claims coding is essential., Experience in a managed care environment is preferred., High school diploma or GED is required..

Key responsabilities:

Adjudicate claims accurately according to company policies and guidelines.

Process various types of claims including professional and facility claims.

Analyze complex claim issues and handle adjustments for corrected claims.

Meet stringent quality and productivity goals for claims processing.

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. In the months and years ahead, we will be offering our services in other states and other markets throughout the nation. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. Our pledge to members is that we will give you exceptional care delivered by compassionate physicians who have a strong commitment to each and every patient. Our physicians work closely with teams of skilled nurses and other healthcare professionals. Prospect Medical contracts with most major health plans, and we serve all product lines, including Commercial, Medicare, Medicaid, Medicare/Medicaid (Medi-Medi) and Health Insurance Exchange. To further improve the health of the communities we serve, Prospect Medical offers comprehensive health education classes and support services through our numerous outreach programs. Diversity and Inclusion Within Our Workforce At Prospect Medical, we believe that a diverse and inclusive environment enriches our workforce and the communities we serve. To that end, we embrace the diversity of our coworkers, physicians, vendors and patients. We do not tolerate harassment or discrimination on the basis of race, ethnicity, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, veteran status or any other characteristics protected by law. We embrace diversity because it is our culture, and it is the right thing to do.

Job description

Job Description

Responsible for consistently and accurately adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy. Process claims according to all CMS and DMHC guidelines. Review, research and process complex claims. Handle recalculation of claims due to incorrect claim payments or where additional information has been received. Investigate and complete open or pended claims. Meet production and quality standards.

Responsibilities

Enter claims information from CMS 1500 (professional) and UB-04 (facility) claims into the IDX claims system. Process all level of claims including Professional, COB, surgery, skilled nursing, lab, Home Health, ER, hospital (in and outpatient), DME, Pharmacy and radiology claims by applying Prospect’s policy and procedures and all claim payment criteria. Analyze complex claim issues and handle all adjustments for corrected claims or when additional information previously requested is received.|Identify and pend claims that require referrals to all support areas (eligibility, Medical management etc) for evaluation or correction of data, tracking these claims to ensure that they are returned and resolved within regulatory guidelines.|Achieve stringent quality goals of 98% administrative accuracy and 99% financial accuracy to contribute to achieving client performance expectations.|Achieve stringent productivity goals of 80/10 claims per day/hr. Initiate recovery of overpaid claims.

Qualifications

Three to five (3-5) years prior medical claims processing experience required. Knowledge of general claims processing principles, CMS claims coding, and UB-04 claims coding, based on at least three to five (3-5) years experience in claims processing preferably in a managed care environment (IPA,MSO)High school diploma or GED.

LOCATION - BASED PAY ADJUSTMENT

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