Description
Hourly Wage Estimate: 23.00 - 33.24 / hour
Learn more about the
benefits offered for this job.
The estimate displayed represents the typical wage range of candidates hired. Factors that may be used to determine your actual salary may include your specific skills, how many years of experience you have and comparison to other employees already in this role. The typical candidate is hired below midpoint of the range.
Introduction
*Qualified candidates must reside in the San Jose, CA market*
Do you have the career opportunities as a Senior Claims Examiner you want with your current employer? We have an exciting opportunity for you to join PPMSI which is part of the nations leading provider of healthcare services, HCA Healthcare.
Benefits
HCA Healthcare, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:
- Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
- Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
- Free counseling services and resources for emotional, physical and financial wellbeing
- 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
- Employee Stock Purchase Plan with 10% off HCA Healthcare stock
- Family support through fertility and family building benefits with Progyny and adoption assistance.
- Referral services for child, elder and pet care, home and auto repair, event planning and more
- Consumer discounts through Abenity and Consumer Discounts
- Retirement readiness, rollover assistance services and preferred banking partnerships
- Education assistance (tuition, student loan, certification support, dependent scholarships)
- Colleague recognition program
- Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
- Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.
Learn more about Employee Benefits
Note: Eligibility for benefits may vary by location.
Our teams are a committed, caring group of colleagues. Do you want to work as a(an) Senior Claims Examiner where your passion for creating positive patient interactions is valued? If you are dedicated to caring for the well-being of others, this could be your next opportunity. We want your knowledge and expertise!
Job Summary and Qualifications
The Senior Claims Examiner primary function is to ensure correct adjudication of all complex claims for SCCIPA contracted plans.
Responsibilities:
- Adjudicate all types of claims, resolving all system edits and audits for hardcopy and electronic claims.
- Resolve provider and eligibility issues relating to received claims.
- Generate emergency reports/authorizations for all received claims which lack prior authorization.
- Adjudicate third party liability and coordination of benefit claims in accordance with policy.
- Review stop loss reports and identify members who are nearing reinsurance levels.
- Identify potential system programming issues and reports issues to supervisor.
- Provide technical support and training for claims processors.
- Recognize and appropriately route claims for carved out services according to Plan contracts.
- Understand Plan contracts, provider pricing, member eligibility, referral authorization procedures, benefit plans and capitation arrangements and processes claims using this knowledge.
- Understand general ledger accounts posting of claims information to the appropriate accounts.
- Work with Customer Service and Provider Services to assist on large claim projects and adjustments.
- Assist with benefit/plan interpretation with customer via the cut-log system when necessary.
Requirements:
- High school diploma
- Three to Five years of experience processing regular and complex claims
- Ability to act as a resource and /or trainer for claims processors
- Knowledge of ICD-9, CPT, HCPC, and Revenue Coding required
- Knowledge of HEDIS, DOC, HCFA and NCQA requirements
- Strong communication skills
- Ability to work under demanding performance standards for production and quality
Supporting HCA Healthcares 186 hospitals and 2,400+ sites of care, Physician Services plays a crucial role as the main entry point for patients looking for high-quality healthcare within the HCA Healthcare system. With a focus on meeting the needs of our patients at all access points, Physician Services is dedicated to implementing innovative, physician-driven, value-added solutions to assist physicians in providing high-quality, patient-centered care, aligning with our mission to care for and enhance human life.
HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in costs for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.
"Bricks and mortar do not make a hospital. People do."- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder
If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Senior Claims Examiner opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today!
We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
