DaVita Claims Examiner III in Las Vegas, Nevada

SUMMARY

The Claims Examiner III adjudicates most complex medical claims including hospital, DME, non-participating hospital and physician claims in time and accurate manner.

ESSENTIAL FUNCTIONS

  • Responsible for quality and continuous improvement within the job scope.

  • Responsible for all actions/responsibilities as described in company controlled documentation for this position.

  • Contributes to and supports the corporation’s quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation’s quality improvement efforts.

  • Processes medical claims (CPT, ICD-10, and Revenue Coding) at productivity standard of 10-15 claims per hour according to contractual agreements.

  • Follows up on claims within one-three day of pending.

  • Reviews batches of claims in order to ensure accuracy of payment.

  • Responds to Member Service inquiries and makes needed adjustments.

  • Attends weekly team meetings.

  • Provides support to Network Services and Administrators.

  • Ensures turnaround time goals are achieved on claims.

  • Edits claims after audit process is complete.

  • Assists other claims examiners as needed.

EXPERIENCE REQUIREMENTS

  • Minimum eight years of claims processing experience, preferably in managed care environment with manual benefit determinations and calculations.

  • Knowledgeable in DRG, modifiers, per diem and other forms of reimbursement required

EDUCATIONAL REQUIREMENTS

  • High school diploma or GED

KNOWLEDGE, SKILLS, ABILITIES

  • Comprehensive knowledge of all coding structures (CPT, IDC-10, HCSPCS, etc)

DaVita Medical Group manages and operates medical groups and affiliated physician networks in California, Colorado, Florida, Nevada, New Mexico, Pennsylvania and Washington. A leading independent medical group in America, DaVita Medical Group has over two decades of experience providing coordinated, outcomes-based medical care in a cost-effective manner. As of June 30, 2017, DaVita Medical Group’s teammates, employed clinicians and affiliated clinicians provided care for approximately 1.7 million patients. DaVita Medical Group’s leadership development initiatives and social responsibility efforts have been recognized by Fortune, Modern Healthcare, Newsweek and WorldBlu.