Providence St. Joseph Health

Job Information

St. Joseph Health / Covenant Health Claim Representative - HSS NSS Claims in Anaheim, California

We are looking for a Claim Representative for the HSS NSS Claims at St. Joseph Heritage Healthcare.

Location: Anaheim, CA

Work Schedule: Full time - 80 Biweekly hours

Shift: 8 hour, Days

Apply Today! Applicants that meet qualifications will receive a text with some additional questions from our Modern Hire system.

Job Summary:

Working under the direction of the Director, this position is responsible for consistently and accurately adjudicating all contracted professional capitated claims with fee- for-service carve outs and, contracted fee-for-service claims for both Commercial and Senior plans within the timeliness and accuracy standards set forth by CMS, Department of Managed Care, AB1455 and the Claims Department polices and procedures.

Essential Functions:

  • Reviews and processes all contracted capitated claims and fee-for-service PCP administration fee for-service claims paid and or denied while achieving and maintaining a 95% accuracy rate.

  • Reviews and processes claims acknowledgment, payment and denial as set forth by CMS, Healthplans and departmental policy and procedures while achieving and maintaining a 95% timeliness standards.

  • Achieving and maintain 95% production requirements per claim type utilizing departmental policy and procedures as established per Healthplan and Network.

  • Recognizes inappropriate CPT, ICD-9 and HCPCS codes and accurately research member eligibility, duplicate claims submissions, out of network services, out of area services and COB and adjudicate according to departmental procedures.

  • Monitors and updates inventory reports in order to track claims in inventory and follows-up on all claims suspended for review purposes or additional information requests until claims are in a final status.

  • Reviews and processes audit errors on a daily basis.

  • Alerts Claims Management of all claims issues that would impact any Healthplan compliance.

Skills :

  • Requires familiarity with computerized claims processing/transaction system.

  • Knowledge of Microsoft windows operating environment required.

  • Possess basic analytical and problem solving skills.

  • Possess good written and verbal communications skills to communicate effectively with individuals at all levels of the organization.

  • Ability to work under general supervision.

  • Ability to work as a team player and have a professional demeanor.

  • Possess excellent organization and prioritization skills.

  • Requires 10-key by touch.

Minimum Position Qualifications:

Education : H.S. Diploma or GED

Experience : 2 years of experience as a Claims Examiner in an IPA, Medical Group or Health Plan.

Preferred Position Qualifications:

Experience :

  • Experience within the Health Care Industry.

  • IDX experience.

Mission Heritage Medical Group is one of California's most respected medical groups. With over 3,000 employees and 75 locations throughout California, including, Northern California, Orange County, High Desert and Los Angeles County, Mission Heritage Medical Group has been continually recognized as a leader in quality, customer service and information technology. This kind of success is the result of team work, a commitment to excellence and a strong adherence to the organization's mission, vision and values. Mission Heritage Medical Group provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Mission Heritage Medical Group complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Company: Heritage Healthcare

Category: Health Care

Req ID: R329243