Claims Processor

This position is responsible for following written criteria, policies and procedures in reviewing and processing claims received from Out of Group providers to determine if such claims are appropriate for payment.  The position also considers eligibility, benefits, authorizations, coding, compliance, contracted payment terms and health plan contracts to decide the disposition of a claim. The contracts can change annually and the examiner must be able to apply the correct terms to the claims.  If the claim is not appropriate for payment, the examiner is responsible for making sure that the denial is done correctly in the system so that the letter will print correctly.  There are internal, external and governmental timeliness standards that consistently need to be met.  This position has the freedom to pay or deny medical services by using the policy guidelines of the department and to process sensitive and confidential information.  If the claim & information received does not meet our department  policy guidelines, this position must refer the claim and documentation to UM department as appropriate.  This position could have contact with Eligibility, Member Services, UM, providers, the Health Plans and any applicable staff.  Additionally, there are production and quality standards that must be maintained.  This position will have responsibility for working independently on assigned tasks and activities, based on established policies and procedures.

Minimum Qualifications:

• High School Graduate or GED
• One year experience in a medical insurance environment.
• Keyboarding skills and the ability to utilize computer equipment and software are required as is experience with other types of standard office equipment.
• Forty-five (45) wpm and 10 key by touch

Preferred Qualifications:

• Familiarity with an electronic practice management system
• Medical terminology

Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service.