We are seeking an experienced Senior Claims Examiner with deep expertise in Medi-Cal Managed Care claims adjudication. The ideal candidate will have extensive knowledge of California Medi-Cal regulations, delegated risk arrangements, provider disputes, and complex facility claim processing. Experience with Medicare and Commercial claims is required, but this role is primarily focused on supporting and serving as a subject matter expert for Medi-Cal business.
Job Purpose
The Claims Examiner III (Medi-Cal Managed Care) is responsible for the accurate processing, adjustment, adjudication, and release of complex hospital, ancillary, and professional claims with a primary focus on Medi-Cal managed care claims. This role requires extensive knowledge of California Medi-Cal regulations, delegated IPA and capitated hospital arrangements, provider disputes, and claims payment requirements.
The ideal candidate is a subject matter expert in Medi-Cal claims processing and is also experienced in Medicare and Commercial lines of business. This individual will identify claim processing issues, perform root cause analysis, recommend operational improvements, support compliance initiatives, and ensure adherence to CMS, DHCS, DMHC, and applicable state regulations. The Claims Examiner III must consistently meet production and quality standards while serving as a resource to other team members.
Duties and responsibilities
- Process, adjust, and adjudicate professional, institutional, and complex claims with a primary focus on Medi-Cal Managed Care, while supporting Medicare and Commercial lines of business.
- Serve as a subject matter expert for Medi-Cal claims processing, reimbursement methodologies, delegated risk arrangements, and applicable regulatory requirements.
- Review and apply provider contracts, benefit plans, divisions of financial responsibility, authorizations, and reimbursement methodologies to ensure accurate claim adjudication.
- Validate diagnosis and procedure codes and ensure claims are processed in accordance with DHCS, DMHC, CMS, AB 1455, AB 1324, and other applicable state and federal regulations.
- Research, analyze, and resolve complex claims issues, payment discrepancies, provider disputes, grievances, escalations, and claims processing errors.
- Process claim adjustments, voids, reopenings, reconsiderations, overpayment recoveries, and underpayment corrections in accordance with departmental guidelines.
- Generate and document provider communications, including acknowledgement, development, denial, resolution, and notification letters as required.
- Collaborate with Customer Service, Provider Relations, Configuration, Compliance, and other departments to resolve claims and payment issues.
- Create and utilize Crystal and SQL reports to support inventory management, operational efficiency, and regulatory turnaround time compliance.
- Identify claims payment errors, system configuration issues, and process improvement opportunities; provide recommendations for corrective action.
- Participate in internal and external audits, regulatory reviews, workflow improvement initiatives, and special projects.
- Meet established productivity and quality standards while maintaining accurate documentation within EZ-Cap and related systems.
- May assist with training, mentoring, check run preparation, and other departmental needs as assigned.
- Comply with all company policies, procedures, and confidentiality requirements.
Qualifications
- 10+ years of claims adjudication experience with significant experience processing Medi-Cal managed care claims.
- Minimum 5 years of experience processing Medicare and Commercial claims.
- Experience using EZ-Cap required.
- Extensive knowledge of California Medi-Cal, Medicare, and Commercial reimbursement methodologies.
- Thorough understanding of DHCS, DMHC, CMS, and applicable state and federal claims regulations.
- Experience with delegated IPA, Medical Group, and capitated provider arrangements.
- Demonstrated experience resolving Provider Disputes (PDRs), claims appeals, grievances, and escalated claims issues.
- Strong understanding of:
- AB 1455 Claims Settlement Practices
- AB 1324 Requirements
- Knox-Keene regulations
- Timely filing requirements
- Coordination of Benefits (COB)
- Claims payment and regulatory turnaround requirements
- Knowledge of CPT, HCPCS, ICD-10, DRG, APC, ASC, and other reimbursement methodologies.
- Proficient in outpatient PPS, inpatient DRG, interim rate payment methodologies, and other reimbursement structures applicable to Medi-Cal, Medicare, and Commercial products.
- Strong analytical, problem-solving, and claims research skills
Working conditions
- This job may require flexible work hours due to the nature of the responsibilities.
Physical requirements
- This job is not considered physically demanding, therefore there are no physical requirements.
