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National Systems America LLP
Plano, TX
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Job Description :
Description: BPS Healthcare American Documented Workers only Day Shift Location: West Sacramento Claims Appeals Examiner 3.1 Job Description: - Examine returns and payments from multiple business entities to determine and make appropriate adjustments, such as approving or denying refunds and claims - Analyze and review claims based on claim types: long term care, inpatient, outpatient, or medical using CA-MMIS program - Calculate provider rate based on the provider rate master file and process adjustments as needed - Complete Claim Inquiry Forms to process provider appeals or claims - Respond to providers in written form by entering appropriate paragraph codes into the appeals sub-system and/or creating text to clarify the response - Resubmit and adjust claims on approved appeals with the proper claim data correction and documentation - Maintain performance within defined qualitative and quantitative objectives - Review and resolve provider appeal within provider manual guidelines - Provide clerical support to management as needed - Ability to research the Provider Manual and policy set by the Department of Health Care Services - Completed Claim Inquiry Forms and Account Receivable to process the provider appeal or claim - Verify recipient eligibility and benefits, revenue, and ICD-9 codes - Ensure timeliness guidelines are met by reviewing the provider documentation Knowledge and Skills: - Basic knowledge of the administrative methods, and an acumen to develop the required administrative skills of the job - Specific level of software skills as required by the work unit - Must have excellent problem-solving skills - Good verbal and written communication skills - Detailed oriented Education and Experience Required: - High school education or equivalent - 1-3 years' experience preferred - Must be a proficient typist and have a minimum of 50 WPM while maintaining a 99.9% accuracy