About this opportunity
Mindlance lists this BusinessOperations - Claims Examiner (Operations) 1 - 700092 opportunity in woodland hills, California. Review the employer’s description below for duties, qualifications and application requirements.
Job description
Claims ProcessorPosition Purpose: Under close supervision, this position processes routine claims within a single product line to determine type and amount of benefit payable. Performs limited duties, subject to review and approval, for the processing of such claims assigned, consistent with applicable policies, procedures and department guidelines. Education/Experience: High School diploma or equivalent required. Minimum six months claims examining experience or completion of a technical class specializing in claims processing required. Experience working with Microsoft applications is preferred.Determines level of reimbursement based on established criteria, provider contract, plan and employer group provisions.Processes all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specification.Matches authorizations to claims, maintains current desk procedural and reference materials.Reviews appeals and complaints; researches any missing or required information.Responds by telephone or in writing to providers, members, or other company departments to process and resolve the claim issue.Story Behind the Need - Business Group & Key ProjectsHealth plan or business unit: Pharmacy Operations Department (Centene Pharmacy Services)Team culture: Inclusive CulturePharmacy Accumulator Audits and BenefitsOur team supports the Health PlanNeed support for SB368 Bill and AB1184 and support for Accumulator Audits and Pharmacy ClaimsOne of our full-time employees recently left our department, so we are short staffedTypical Day in the RoleDaily schedule & OT expectationsTypical task breakdown and rhythmInteraction level with teamWork environment descriptionHandle Combined Pharmacy/Medical Accumulator ReviewPharmacy Claims Review (Coordination of Benefits, Dual Coverage, Foreign, Prior Insurance, Medicare Secondary Payor, Compounds, Copay Adjustments, Out of Network, Skilled Nursing/Custodial, Cruise Ship, Retroactive Prior Auth Requests, Out of Area Emergency, Third party (I.e. Medi-Cal), Veterans Administration, Universal Claim Forms, Verification of Rx Copay Card Usage for Brand medicationsMember Eligibility UpdatesACD Phone Line Coverage for Exchange MembersCall pharmacies to verify drug information and Rx copay card usageReview and audit Explanation of Benefits for multiple plans per SB368 BillCompelling Story & Candidate Value PropositionWhat makes this role interesting?Points about team cultureCompetitive market comparisonUnique selling pointsValue added or experience gainedFlexibility and Work Life BalanceCompensation and BenefitsCareer Growth and LearningInclusive CultureImpact and PurposeCandidate RequirementsEducation/Certification - Required: High school diploma or higher education - Preferred: High school diploma or higher educationLicensure - Required: No License Required - Preferred: CA Pharmacy Technician LicenseYears of experience requiredDisqualifiersBest vs. averagePerformance indicators - Must haves:Pharmacy or Medical claims processingPhone Experience/Customer Service ExperienceMicrosoft Word, Excel, OutlookCandidate Review & SelectionShortlisting processSecond touchpoint for feedbackInterview InformationOnboard Process and Expectations
Who can apply
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