Claims Examiner I

About Us : Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.

SUMMARY : Under the direction of the Vice President of Claims, this position is responsible for manual input and adjudication of claims submitted to the health plan. The ideal candidate will need to interpret and utilize capitation contracts, payor matrixes, subscriber benefit plan, and provider contracts; as well as resolving customer service inquiries, status calls, andclaim tracers.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following :

• Data enter paper claims into EZCAP.
• Review and interpret provider contracts to properly adjudicate claims.
• Review and interpret Division of Financial Responsibility (DOFR) for claims processing.
• Perform delegated duties in a timely and efficient manner.
• Verify eligibility and benefits as necessary to properly apply co-pays.
• Understands eligibility, enrollment, and authorization process.
• Knowledge of prompt payment guidelines for clean and unclean claims
• Process claims efficiently and maintains acceptable quality of at least 95% on reviewed claims.
• Meets daily production standards set for the department.
• Prepares claims for medical review and signature review per processing guidelines.
• Identify the correctly received date on claims, with knowledge of all time frames for meeting compliance for all lines of business.

Maintains good working knowledge of system / internet and online tools used to process claims

QUALIFICATION REQUIREMENTS : To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. 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.

EDUCATION and / or EXPERIENCE :