Claims Examiner

At WelbeHealth, we are transforming the reality of senior care by providing an all-inclusive healthcare option to the most vulnerable senior population, while serving as a care provider and care plan to those individuals we serve.

Our Health Plan Services team helps ensure excellent care delivery for our participants, and the Claims Examiner plays a pivotal role in ensuring timely and efficient processing of claims for our contracted specialty provider partners.

• Examine, review and process claims according to contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
• Assess appropriateness of returned, denied, or paid claims by reviewing and following contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
• Ensure claim timeliness processing standards are being met
• Work alongside manager to establish and maintain claims processing rules that meet all regulatory and business requirements
• Assist internal and external partners with questions related to claims decisions or claims statuses
• Maintain a comprehensive understanding of claim processing guidelines at both the federal and state level

• High School Diploma or Equivalency, professional experience may be substituted
• Minimum of three (3) years of experience with processing, researching, and adjudicating claims in a complex managed care environment
• Working knowledge of the health plan insurance industry and CPT/HCPCS procedure codes, and relevant federal and state regulations
• Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee  schedule, Diagnosis Related Groups (DRG), Multiple Procedure Payment Reduction (MPPR) and benefit interpretation and administration 
• In depth experience with Medicare and Medicaid claims processing
• Demonstrated skills within Microsoft Office Applications & electronic claims processing systems
• Strong organizational, analytical, communication, and time management skills

At WelbeHealth, our mission is to unlock the full potential of our vulnerable seniors. In this spirit, please note that we have a vaccination policy for all our employees and proof of vaccination, or a vaccine declination form will be required prior to employment. WelbeHealth maintains required infection control and PPE standards and has requirements relevant to all team members regarding vaccinations.

At WelbeHealth, we embrace and cherish the diversity of our team members, and we're committed to building a culture of inclusion and belonging. We're proud to be an equal opportunity employer. People seeking employment at WelbeHealth are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law.

Please ensure your application is being submitted through a WelbeHealth sponsored site only. Our emails will come from @welbehealth.com email addresses. You will never be asked to purchase your own employment equipment. You can report suspected scam activity to fraud.report@welbehealth.com