Senior 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 Senior Claims Examiner plays a pivotal role in ensuring timely and efficient processing of claims for our contracted specialty provider partners.

Essential Job Duties:

• Examine claim records and forms to investigate and resolve first level disputes, including completion of acknowledgement and determination letters
• Review and process second level claims, such as adjustments and corrected claims
• Work closely with leadership on identified trends related to improper processing and claim-related concerns or discrepancies that result in a dispute
• Assist the team in carrying out departmental responsibilities and collaborate with others to support short- and long-term goals and priorities
• Establish and maintain effective working relationships with team and collaboration with interdepartmental staff and leadership
• Work closely with leadership on identified trends related to improper processing and claim related concerns or discrepancies that result in a dispute

Job Requirements:

• Minimum of three (3) years’ health plan claims processing experience, and two (2) years’ health plan claims dispute experience analyzing and resolving provider claims problems
• Experience in a Managed Care Plan (MCP) or PACE organization (PO) claims processing environment highly preferred
• In depth experience with Medicare and Medicaid claims processing
• Strong computer and appropriate software knowledge (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word, Teams) and job specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the
  position
• Ability to balance competing priorities, exercise discretion, and consider all relevant factors in navigating gray areas and resolving ambiguities
• Proficient in the principles and practices of managed health care, health care systems and medical terminology (e.g., revenue Codes, Current procedural Terminology (CPT), Healthcare Common Procedure Coding system (HCPCS) and Internal Classification of Disease (ICD-10)
• Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee schedule and Diagnosis Related Groups (DRG) and benefit interpretation and administration

Benefits of Working at WelbeHealth: Apply your claims expertise in meaningful ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for.

• Medical insurance coverage (Medical, Dental, Vision)
• Work/life balance – we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, and 6 sick days
• Advancement opportunities - We’ve got a track record of hiring and promoting from within, meaning you can create your own path!
• And additional benefits