Job Information
Stanford Health Care Claim Examiner III (Accountable Care) in United States
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Day - 08 Hour (United States of America)
This is a Stanford Health Care job.
A Brief Overview
The Claims Examiner III is responsible for independently reviewing, adjudicating and finalizing Provider Dispute Resolution (PDR) requests, processing claims, appeals, adjustments and special projects. Typical duties include researching complex claim inquiries, reviewing medical and benefit necessary documentation, and applying appropriate policies and procedure and finalize claims adjustment. Process professional and institutional electronic and paper medical claims. Meeting established Claims Department claims processing quality and production performance benchmarks. Effectively managing workload and prioritizing assignments. Working without significant guidance. Ensuring claims adjudication is in accordance with State, Federal and Health plan regulatory requirements as well as departmental guidelines.
Locations
Stanford Health Care
What you will do
Claims Processing:
Reviews, analyzes, and finalizes PDR’s, special projects, claims adjustment requests in accordance with departmental, Health plan, and regulatory timeliness and accuracy standards.
Assists with special projects, to include review and adjustment of special project claims.
Utilizes appropriate reference materials and policies to research information, respond to inquiries, resolve problems/issues and process claims accurately.
Reviews capitation issues and investigates COB claims Medicare Secondary Payer requests.
Process pending medical claims when needed.
Meets established departmental quality, production, and turnaround time performance benchmarks.
Acknowledges and applies information discussed at staff meetings in-service training.
Makes significant contributions to the work team and demonstrates full competence in own work area.
Performs other duties as assigned and participates in organization projects as assigned.
Adheres to safety, P4P’s (if applicable), HIPAA and compliance policies.
Occasional travel to the office for team meetings or as needed.
Education Qualifications
- High school graduate.
Experience Qualifications
Five (5) years prior claims processing experience in an IPA, health plan or HMO related setting.
Knowledge of and working experience with ICD-10, CPT and HCPC coding systems.
Thorough knowledge of medical terminology, benefit plans enrollment and membership activities.
Advanced knowledge of claim processing procedures.
To be able to perform accurate adjustments of claims.
Basic understanding of Microsoft Word and Excel applications.
Required Knowledge, Skills and Abilities
Ability to work independently and prioritize multiple work assignments.
Independent decision-making skills and demonstrated initiative to resolve.
Excellent oral and written communication skills.
Ability to work in a fast-paced environment.
Able to assess and coordinate departmental work flows effectively.
Ability to process all types of medical claims and interpret authorizations, contracts, and physician reimbursement methodologies.
Physical Demands
Constant Sitting.
Frequent Walking.
Occasional Standing.
Occasional Bending.
Occasional Squatting.
Occasional Kneeling.
Constant Hand Use.
Constant Repetitive Motion Hand Use.
Frequent Grasping.
Frequent Pushing and Pulling.
Occasional Reaching (above shoulder level).
Frequent Twisting and Turning (Neck and Waist).
Constant Vision (Color, Peripheral, Distance, Focus).
These principles apply to ALL employees:
SHC Commitment to Providing an Exceptional Patient & Family Experience
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.
You will do this by executing against our three experience pillars, from the patient and family’s perspective:
Know Me: Anticipate my needs and status to deliver effective care
Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
Coordinate for Me: Own the complexity of my care through coordination
Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
Base Pay Scale: Generally starting at $30.32 - $38.66 per hour
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.
At Stanford Health Care, we seek to provide patients with the very best in diagnosis and treatment, with outstanding quality, compassion and coordination. With an unmatched track record of scientific discovery, technological innovation and translational medicine, Stanford Medicine physicians are pioneering leading edge therapies today that will change the way health care is delivered tomorrow.
As part of our spirit of discovery, we also leverage our deep relationships with luminary Silicon Valley companies to develop new ways to deliver preeminent patient care.
Learn about our awards (https://stanfordhealthcare.org/about-us/awards.html) and significant events (https://stanfordhealthcare.org/about-us/our-history.html) .