Providence Health & Services Facility Claims Examiner in Mission Hills, California
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Providence is calling a Facility Claims Examiner (Full-Time/Day Shift) to Providence Facey Medical Foundation in Mission Hills, CA.
Please upload a current resume reflecting all professional nursing experience.
We are seeking a Facility Claims Examiner who will be responsible for the processing of complex institutional claims (stop loss, contracted, non-contracted, per diem, case rate etc.) and adjudication and claims research when necessary. He/She must have knowledge of compliance issues as they relate to claims processing and ability to identify and address non-contracted providers.
In this position you will:
Deliver upon the service expectations of both our patients and fellow staff members by listening to their needs; engaging in positive interactions; and following through on promises made in a thoughtful, efficient, timely and courteous manner so that their total outcome is better than expected.
Respect the dignity, confidentiality and privacy of patients.
Work in a safe manner, adhering to general safety precautions and standards. Report any unsafe conditions to their supervisor and/or the safety hotline.
Validate the information on all UB-04 and CMS-1500 forms and adjudicates facility claims such as an inpatient facility, outpatient surgery facility, emergency room (ER) facility, skilled nursing facility (SNF), home health care (HHC), dialysis facility, ambulatory surgical center (ASC) facility, ambulance, durable medical equipment (DME), endoscopy facility claims for payment according to an established contractual agreement, existing letter of agreement (LOA), Medicare or Medi-Cal fee schedules.
Thoroughly reviews claims to ensure that there is no missing information and the claim is clean.
Must be resourceful, detail-oriented, and is knowledgeable with the use of a DRG, APC, Psych, Home Health, SNF, and Dialysis pricer.
Have knowledge of the industry standard state mandated rules such as ones governed by the Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), and the state of California’s Medi-Cal Program.
Be knowledgeable with the application of the division of financial responsibilities (DOFRs) between Providence Ministries, Health plans, IPAs, and Medical groups.
Required qualifications for this position include :
2 years claims pricing and processing experience in ambulatory, acute care hospital, HMO or IPA environment.
Experience processing all types of medical claims outpatient/inpatient UB-04 and HCFA-1500 claims as well as others.
Must have knowledge of payment methodologies for: Professional (MD), Hospital, Skilled Nursing Facilities, and Ancillary Services.
Must have thorough understanding of timeliness and payment accuracy guidelines for commercial, senior and Medi-Cal claims.
Deals effectively in a fast-paced, changing environment.
Ability to work independently as well as be part of a team.
Develops effective working relationships with all levels of the organization, including administration, doctors and staff.
Must be familiar with computerized claims processing systems.
Data entry and 10-key skills by touch and sight.
Knowledge of CPT/HCPC and ICD10 coding, procedures and guidelines.
Comprehensive medical terminology and knowledge.
Efficiency and accuracy of claim payments during processing and adjudication.
Preferred qualifications for this position include:
- Experienced in interpreting provider contract reimbursement terms.
About the organization you will serve:
Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita, San Gabriel and Simi Valleys. The group began as a single medical practice over 90 years ago.
Facey is part of Providence Health & Services, an integrated, not-for-profit 5-state network of hospitals, care centers, medical clinics, affiliated services and educational facilities spanning from California to Alaska.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Claims
Location: California-Mission Hills
Req ID: 305647