• Address: Los Angeles, CA 90030 (map)
• Date Posted: 11/07/09
• Job Type: Full-time

Fantastic career opportunity for the Medical Claims Examiner in the Los Angeles area.

This position provides an ambitious high-achiever with the opportunity to add valuable insight and experience to an already well-developed foundation of knowledge and skills. In particular, the right candidate will have a passion to work for a company that values leadership, empowerment, flexibility, and an entrepreneurial spirit.

Summary:
Process clinical claims for payments. Request information from internal or external sources to ensure completeness and validity of claim and medical information. Research claims and answer inquiries. Using ISSI Software, sort claims according to network status. Enter claim information for re-pricing. Maintain a high level of accuracy and production rate. Requires medical background and familiarity with medical and insurance terminology.

The Claims Examiner responsibilities:
- Analyze and process complex or technically difficult claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
- Assess liability and resolve claims within evaluation.
- Negotiate settlement of claims up to designated authority level.
- Calculate and assign timely and appropriate reserve to claim; monitor reserve adequacy throughout the life of the claim.
- Calculate and pay benefits due; approve and make timely claim payments and adjustments; and settle claims within designated authority level.
- Prepare necessary state filings within statutory limits.
- Manage the litigation process; ensure timely and cost effective claim resolution.
- Coordinate vendor referrals for additional investigation and/or litigation management.
- Use appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.
- Manage claim recoveries, including but not limited to subrogation, second injury fund recoveries and Social Security offsets.
- Report claims to the excess carrier; responds to requests of directions in a professional and timely manner.
- Communicate claim activity and processing with the ill or injured party and the client; maintains professional client relationships.
- Ensure claim files are properly documented and claim coding is correct.
- Refer cases as appropriate to supervisor and management.
- Maintain a quality assurance program to support the total performance management initiative and the consistent delivery of quality claims service.
- Perform other duties as assigned.

Skills & Knowledge:
In-depth knowledge of appropriate health insurance principles and laws for line-of-business handled, recoveries, offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security application procedures as applicable to line-of-business. Excellent oral and written communication skills; PC literate, including Microsoft Office products. Analytical and interpretive skills, strong organizational skills, excellent negotiating skills. Good interpersonal skills, ability to work in a team environment,

Requirements:
- Four (2) years of claims management experience required
- Knowledge of electronic claims processing – ISSI software desired

This is a contract/project position for 3 months located in Los Angeles, CA
Schedule: Monday – Friday 8am – 4pm

If you are available and interested in this opportunity, please contact forward your current resume in a Word document or a PDF file format attachment to us via email to 148t@kellyservices.com

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