Medix
You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
Our client is seeking a Claims Examiner responsible for the accurate review, processing, and adjudication of complex Medicare Advantage medical claims. The role involves analyzing claims against CMS regulations and working closely with various departments to resolve high-dollar and high-complexity claims.
Responsibilities / Job Duties
Accurately review, process, and adjudicate complex Medicare Advantage medical claims including inpatient, outpatient, professional, and ancillary claims. Analyze claims against applicable CMS regulations, Medicare Advantage Evidence of Coverage (EOC), benefit designs, and provider contracts. Resolve high-dollar, high-complexity, and pended claims requiring research and coordination with other departments. Ensure claims are processed in compliance with CMS claims payment rules, Medicare Secondary Payer guidelines, NCDs/LCDs, and plan-specific guidelines. Maintain clear and thorough documentation on claim actions in the claims system. Participate in CMS and internal audits by providing supporting documentation and claim resolution explanations. Schedule / Shift
Mon-Fri (8 AM to 5 PM or 9 AM to 6 PM), On-site
Location : Onsite / Huntington, CA
Benefits
Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances). Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)). 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1). Short Term Disability Insurance. Term Life Insurance Plan.
* We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we're dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
Job Summary
Our client is seeking a Claims Examiner responsible for the accurate review, processing, and adjudication of complex Medicare Advantage medical claims. The role involves analyzing claims against CMS regulations and working closely with various departments to resolve high-dollar and high-complexity claims.
Responsibilities / Job Duties
Accurately review, process, and adjudicate complex Medicare Advantage medical claims including inpatient, outpatient, professional, and ancillary claims. Analyze claims against applicable CMS regulations, Medicare Advantage Evidence of Coverage (EOC), benefit designs, and provider contracts. Resolve high-dollar, high-complexity, and pended claims requiring research and coordination with other departments. Ensure claims are processed in compliance with CMS claims payment rules, Medicare Secondary Payer guidelines, NCDs/LCDs, and plan-specific guidelines. Maintain clear and thorough documentation on claim actions in the claims system. Participate in CMS and internal audits by providing supporting documentation and claim resolution explanations. Schedule / Shift
Mon-Fri (8 AM to 5 PM or 9 AM to 6 PM), On-site
Location : Onsite / Huntington, CA
Benefits
Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances). Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)). 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1). Short Term Disability Insurance. Term Life Insurance Plan.
* We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we're dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.