SBS - Claims Examiner

Santa Barbara Select is an Independent Physician Association (IPA) that functions under Desert Physicians Management (DPM). DPM is a physician-owned managed care network with 200+ physicians and multiple urgent care facilities.

Some administrative responsibilities provided are:

• Managed care operations
• Claims adjudication
• Utilization management
• Provider network administration Job Summary We are seeking a detail-oriented and proactive Claims Examiner to join our claims processing team.

The ideal candidate will possess strong analysis skills and a thorough understanding of workers' compensation law, with the ability to evaluate and process claims efficiently. This role involves investigating claims, detecting potential fraud, and ensuring accurate adjudication while delivering exceptional customer service. Duties

Claim Adjudication:

Analyze and process healthcare claims for all lines of business, verifying accuracy against medical records, diagnoses, authorization, treatments and accuracy of billing.

Compliance:

Ensure claims comply with CMS, DMHC, DHS and other governmental regulations including Choice Physicians & RINCON Network's policies and procedures.

Data Integrity:

Ensure that all information is accurately entered into the claims system by appropriately validating the information.

• Discrepancy resolution: Investigate and resolve any discrepancies to avoid provider abrasion.
• High dollar and complex claims adjudication: Process difficult claims to completion to ensure tracking and management of IBNR and other metrics can be tracked for financial purposes.

Payment Determination:

Make accurate payments by using resources adequately to append appropriate amounts or deny according to industry guidelines.

Use Acquired Expertise:

Apply all knowledge of CPT, ICD-10, Revenue, Bill Type, HCPCS, and code sets needed to complete a claim.

Pricing Software:

Accurately utilize claim pricing software to guarantee the best outcome and payment of claims

• Perform other duties as assigned Qualifications
• Experience with adjudicating Institutional/Facility claims.
• Strong organization skills: ability to multitask, properly manage time, and meet timelines.
• Knowledge of Medicare and Commercial rules and regulations
• Knowledge of using claims processing and reporting software particularly Crystal Reports/Ez-Cap.
• Knowledge of calculating and applying DRG/APC/ASC/Per Diem/Medicare Physician Fee Schedules/Etc. rates.
• Minimum three (3) years Claims experience in a Managed Care/Medical Group Claims department, specifically adjudicating professional

CMS-1500

claims.

• Must have knowledge and the ability to interpret Health plan, Provider, and Vendor Contracts This is a great opportunity to become a part of a growing organization that is dedicated to improving healthcare experience.

Apply today and join us in our mission to deliver superior services, ensuring health and quality of life to the people in the communities we serve! Equal Employment Opportunity (EEO)/Americans with Disabilities Act (ADA): We are an Equal Employment Opportunity (EEO) and Americans with Disabilities Act (ADA) compliant employer, committed to providing equal employment opportunity to all employees and applicants.

Pay:

$22.00 - $32.00 per hour

Benefits:

401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance

Work Location:

In person