Tenet Healthcare Sr. Claims Examiner Specialist in Encino, California

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health Solutions is a leading healthcare business process management services provider working to improve operational performance for more than 600 clients so they can support financial improvement, enhance the patient experience, and drive value-based performance. Through our revenue cycle management, patient communications, and value-based care solutions, we empower healthcare decision makers—hospitals, health systems, physicians, self-insured employers, and payers—to better connect every point of care and wellness management. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Conifer Health Solutions is currently hiring for a Sr. Claims Examiner Specialist.

JOB SUMMARY

Responsible for the accurate and timely review of complex claims in accordance with applicable contracts, state and federal regulations, health plan requirements, policies and procedures, and generally accepted business practices.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

  • Analyzes professional and hospital claims for accuracy according to set dollar thresholds and meets and maintains production and quality standards. 50%

  • Reviews authorization and/or provider's contract and adjudicates claims accordingly. 30%

  • Perform any correspondence, follow-up and any projects delegated by claims supervisor.10%

  • Provide assistance to the customer service department with escalated member issues. 10%

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • General office equipment experience (i.e. photocopier, fax, calculator, ability to operate a PC and previous exposure to the Microsoft Windows environment).

  • Must have an excellent understanding of health and managed care concepts and their application in the adjudication of claims.

  • Strong working knowledge of ICD.9.CM, CPT, HCPCS, RBRVS coding schemes and medical terminology.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

  • High School Diploma or Equivalent preferred

  • 3-5 years of claims processing experience in a PPO, self-funded, and/or HMO setting preferred

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Must be able to work in sitting position, use computer and answer telephone

  • Ability to travel

  • Light physical effort (lift up to 10lbs). Regularly needs to be able to bend, stoop and reach to file.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Office Work Environment

TRAVEL

  • Approximately 0% travel may be required

Job: Conifer Health Solutions

Organization: Conifer Value Based Care

Title: Sr. Claims Examiner Specialist

Location: CA-Encino

Requisition ID: 1705026378