Job Summary:
Responsible for adjudicating claims in accordance with policies, procedures and guidelines, our Claims Examiner will process claims according to all CMS and DMHC guidelines, review and investigate claims data of more complex claims, investigate and complete open or pended claims, and create adjustments to correct claim payments process.

The following job functions are included, but not limited to:
Enter claims information from CMS 1500 (professional) and UB-04 (facility) claims into the IDX claims system online
Respond to complex service requests, adjusting claims as appropriate to resolve payment issues
Processing all level of claims including COB, Hospital, Pharmacy, Skilled Nursing, and DME bills
Other duties as requested

Requirements and/or Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Detailed knowledge of general claims processing principles, CMS claims coding, based on at least 2 years experience in claims processing, customer service, or medical billing, preferably in a managed care environment
Ability to apply general processing procedures and Prospect's specific guidelines to claims data to make valid decisions on claims liability
Achieve quality goals of 98% administrative accuracy and 99% financial accuracy to contribute to achieving client performance expectations
Achieve productivity goals of 125/15.63 claims per day/hr
Ability to analyze complex claims problems and accurately resolve payment issues
Ability to successfully perform in a fast paced environment with high production standards and employee expectations
Ability to work well with management and team members to contribute to the achievement of departmental goals
Availability to work overtime, as needed
Knowledge of IDX is a plus

To apply for this position, please send your resume and salary history to: hr@prospectmedical.com. Please include the job title in the subject line.