Claims Examiner II & III
Affinity Medical Solutions (Division of University Healthcare Alliance) - Richmond, CA

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Exciting new opportunities exists to be part of the team at University HealthCare Alliance (UHA), Stanford Hospital & Clinics’ new medical foundation. These opportunities are based in Richmond, CA with our Affinity Medical Solutions Division.

These positions are responsible for meeting established Claims Department claims processing quality and production performance benchmarks, researching/reviewing necessary documentation and applying claims policies appropriately and accurately in order to review, adjudicate and finalize claims, and ensuring claims adjudication is in accordance with state, federal and health plan regulatory requirements as well as departmental guidelines. Additionally, both positions will independently review, adjudicate and finalize professional and institutional electronic and paper medical claims. The Claims Examiner III will additionally be responsible for Provider Dispute Resolutions (PDR) requests, processing claims adjustments requests received from customer service and adjudicating special project claims.

These positions require a HS graduate, knowledge of and work experience with ICD-9, CPT and HCPC coding systems, thorough knowledge of medical terminology, enrollment and membership activities and claims processing procedures/systems, as well as a basic understanding of Word and Excel. Must be able to work independently, exercise good judgment, take initiative, excel in a fast-paced environment, process all types of medical claims and interpret authorizations, contracts and physician reimbursement methodologies. The ability to assess and coordinate departmental work flows effectively and good organizational, prioritization, decision making and verbal/written communication skills are necessary. The Claims Examiner II role requires 3 years of claims process experience in an IPA or HMO related setting. The Claims Examiner III opening requires 5 years of this experience, while experience with claims adjustments and PDRs is preferred.

If you are interested please send your resume and cover letter.