Job Details

At WelbeHealth, we make the impossible, possible for underserved seniors. We do this through utilizing and developing cutting-edge healthcare and well-being service products especially for seniors and their families. Now is your chance to join our talented team that delivers unparalleled creative healthcare, insurance, social support and more to seniors. We create senior well-being through our courage to love, pioneering spirit and shared intention. These values permeate everything we do. At WelbeHealth, you'll help inspire that magic by enabling our teams to push the limits of healthcare and well-being experiences and create the never-before-seen!**Job Summary:**The Claims Examiner will collaborate with our Third Party Administrator (TPA), providernetwork, and other internal stakeholders to ensure an accurate, timely, compliant and efficientclaims processing experience. The emphasis of this role will be placed on the ability to workindependently, meet deadlines and understand complex medical claims. The ideal candidatewill have strong knowledge of the healthcare industry. The Claims Examiner collaborateseffectively with colleagues and stakeholders to promote the WelbeHealth values, team cultureand mission.**II. Duties and Responsibilities:**• Determines appropriateness of returned, denied or paid claims by reviewing andfollowing contractual obligations, federal and state regulations, organizational policiesand procedures, or other established quality standards.• Monitors claims inventory and ensures timeliness standards are being met.• Works alongside manager to establish and maintain claims processing rules that meetall regulatory and business requirements.• Responsible for receiving, researching and responding to provider claim appeals.• Coordinates the receipt, tracking, review, and processing of Home Care invoices.• Assists internal and external partners with questions related to claim decisions or claimstatus.• Navigates systems as needed during audit and provides any follow up requested byauditors.• Provides input on appropriate short and long term departmental KPI targets andperiodically provides objective evidence of progress towards achieving the desiredresult(s).• Creates and distribute necessary operational reporting in a manner that provides thebroader organization with key data and insight as to the state of claim operations.• Reviews and report monthly on out-of-network usage.• Researches complex claims pending additional action prior to payment.• Supports the finance team by providing input on appropriateness of IBNR accruals.• Outreaches participating and non-participating providers to obtain W9 forms.• Supports provider team in successful translation of internal encounters to claimstransmission to the TPA for processing.• Suggests enhancements to claims audit tools, policies, and documents.• Complete all required documentation in a timely and accurate manner.• Protect privacy and maintain confidentiality of all company procedures and informationabout team members, participants, and families.• Follow WelbeHealth policies and procedures and participate in any required QualityImprovement activities, staff training and meetings.• Communicate regularly with Supervisor and team regarding workload and priorities.• Timely completion of all mandated trainings and education.• Timely completion of all mandated occupational health screenings as needed.• Maintain California Driver's License and maintain in good standing.• Exercises flexibility in performing assignments as business needs evolve.• Other duties as assigned.**III. Qualifications and Requirements:**Education/Training Certifications:• Bachelor's Degree required or combination of 3+ claims related work and educationalexperience may be substituted.**Skills and Experience:**• Minimum of three years' of experience processing, researching and adjudicating claims.• Working knowledge of the health plan insurance industry, CPT/HCPCS procedurecodes, and relevant federal and state regulations.• Strong organizational, analytical, communication, and time management skills• Excellent critical thinking and decision-making skills.• High attention to detail.• Excellent organizational and communication skills.• Ability to work independently with minimal supervision.• Demonstrated ability to prioritize in a fast-paced environment.• Experience and competency working with people from diverse backgrounds andcultures.• Commitment to unlocking the full potential of our most vulnerable seniors.**COVID-19 Vaccination Policy**At WelbeHealth, our mission is to unlock the full potential of our vulnerable seniors. In this spirit, please note that we have a vaccination policy for all of our employees and proof of vaccination prior to employment is required.**Our Commitment to Diversity, Equity and Inclusion**At WelbeHealth, we embrace and cherish the diversity of our team members, and we're committed to building a culture of inclusion and belonging. We're proud to be an equal opportunity employer. People seeking employment at WelbeHealth are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law.