Local 1014, the self-funded ERISA Trust dedicated to serving the wellbeing of the Los Angels County Fire Fighters and their families, is seeking a full-time medical Senior Claims Adjuster. The ideal candidate will be processing more complex claims and should be extremely confident and will be trusted to make independent decisions. The SCA should be highly effective in communication and writing correspondence. The position is going to be strictly internal, Monday to Friday with frequent potential for overtime.

Position Overview:

The Senior Claims Adjuster will be handling facility, ancillary, and Blue Card claims based on medical authorization and apply all applicable coding edits, contractual agreements, and Plan provisions, as well as claims requiring greater confidentiality. Provide back-up support to Member Services, fielding incoming telephone calls from members and providers as needed upon request of Claims Manager. Train and advise other claims adjusters, serve as workflow coordinator for the Claims Department as needed, and perform various system-related tasks including data transmission. While certain companies find ways to deny claims, we find ways to approve them.

Essential Job Functions:

• Process paper (manual) and electronic professional, facility, ancillary, and Blue Card (out of state) claim submissions as appropriate (pay, deny, pend).
• Process paper (manual) and electronic professional, facility, ancillary VIP claims that require greater confidentiality.
• Research, resolve and process adjustment claims (active or re-opened) that are more difficult, complex or escalated claims.
• Process out of network claims requiring negotiation by E-Plan vendor.
• Train and advise other claim adjusters as requested by Claims Manager.
• Serve as workflow coordinator for the Claims Department in the absence of the Claims Manager and/or Benefit Specialist.
• Review all claims for potential fraud, waste and abuse, hospital acquired conditions and events.
• Identify claims with Workers’ Compensation or Third Party Liability potential and refer to appropriate area for further investigation.
• Identify claims requiring clinical review, obtain appropriate medical records, and refer to Claims Manager for review.
• Interface with members and providers; periodically follow-up on pended claims; completion of error corrections; and adjustment of claims as necessary.
• Function as a member services representative when necessary as requested by Claims Manager.
• Consistently meet established productivity, schedule adherence, and quality standards.
• Other duties as assigned by the Claims Manager.

Required Knowledge/Skills/Abilities/Experience

• Minimum of 10 years recent experience required,
• 10+ years desired as a health claims examiner processing Group Medical claims or equivalent education/experience such as healthcare benefits, benefit administration or health care delivery from either a payer or provider perspective.
• Expert knowledge of medical terminology, facility and physician billing practices, and CPT, ICD-9/ICD-10, HCPCS, DRG and Revenue code coding methodologies.
• Expert knowledge of the Plan in terms of covered expenses and exclusions, coordination of benefits and third-party liability provisions.
• Strong decision making, research and analytical abilities.
• Excellent typing and 10-key skills.
• Ability to work under pressure and adapt to changing environments.
• Familiarity with computer and Windows PC applications; ability to learn new and complex computer system applications, and to navigate between various computer applications/systems to conduct research and to respond to members and providers.
• Ability to communicate clearly and professionally, both verbally and in writing.
• Solid organizational skills with strong attention to detail and listening skills.
• Possess a strong work ethic and team player mentality.

Amazing Compensation & Benefits Package (all start day 1 of employment)

• $69k - $79k (with opportunity for overtime)
• 100% covered benefits for employee AND dependents
• 401k Matching up to 8.3% of base pay
• 13 holidays, 2 weeks vacation, 12 sick days100% covered benefits for employees and dependents
• Mon - Fri 8:30 - 4:30 (no holidays or weekends)

If interested, please send us your resume and cover letter today for immediate consideration!

Job Type: Full-time

Pay: $69,000.00 - $79,000.00 per year

Benefits:

• Dental insurance
• Employee assistance program
• Health insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday
• Overtime

Application Question(s):

• Are you willing to work in El Monte?
• Are you willing to undergo a background check, in accordance with local law/regulations?

Experience:

• Group Medical Claims Processing: 10 years (Preferred)
• Medical terminology: 10 years (Preferred)
• BlueCard Claims Processing: 5 years (Preferred)
• Supervisory: 4 years (Preferred)
• Medical Claims Adjusting: 10 years (Preferred)

Work Location: One location

Please Note :
bankofmontserrat.ms is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, bankofmontserrat.ms provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.