The Claims Examiner is responsible for accurately and consistently adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy. Processes claims according to all CMS and DMHC guidelines. Investigate and complete open or pended claims. Meet production and quality standards.
Essential Job Duties: * Meets productivity standards for number claims completed and for accuracy of entries. * Handles in a professional and confidential manner all correspondence. * Supports CSMNS core values, policies, and procedures. * Receives, and adjudicates medical claims for processing; reviews scanned, EDI, or manual documents for pertinent data on claim for complete and accurate information. * Receives daily workflow via reports or work queue and incoming phone calls. * Researches claims for appropriate support documents. * Analyzes and adjusts data, determines appropriate codes, fees and ensures timely filing and contract rates are applied. * Responds and documents resolution of inquiries from internal departments. * Assists Finance with researching provider information to resolve outstanding or stale dated check issues. * Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases.
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research... and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.