Job Details

Claims Examiner I

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We?

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.

Why Join Us?

We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

Under close supervision, Claims Examiner I process non-complex paper or electronic claims, handling from inception to conclusion within established authority and guidelines.

This position requires considerable interaction with clients, claimants on the phone, with management, other Claims Examiners, and other staff in the office; therefore, consistently being at work in the office or home office location as applicable, in a timely manner, is inherently required of this position.

Functions & Job Responsibilities

Be familiar and comply with all company policies and procedures.

Effectively manages a caseload of 50-150 claims a day

Initiates and conducts claim investigation in a timely manner.

Achieve claims processing standards for accurate and timely claims adjudication.

Maintain claims processing standards to meet performance appraisal goals.

Determines compensability of claims and administer benefits, based upon product benefits and CMS guidelines.

Manages medical treatment and medical billing, authorizing as appropriate, with requests for surgical treatment to be referred to supervisor prior to authorizing.

Communicates with provider regarding claims issues

Computes and processes payment.

Finalizes all claims and obtains authority as designated.

Maintains documentation in file to reflect the status of and work being performed on the file.

Communicates appropriate information promptly to the client to resolve claims efficiently.

Involves supervisory staff when appropriate.

Adheres to all Company policies and procedures.

Participates in audits and file reviews, as needed.

Performs other duties as assigned to include but not limited to assisting Document Processing Associate.

Other duties as assigned, mailroom tasks.

Qualifications

Education & Experience:

Associate degree. Bachelor's degree in related field preferred

One (1) year related experience; or equivalent combination of education and experience.

Skills:

Technical knowledge of statutory regulations and medical terminology.

Familiar with CMS claims payment, billing guidance.

Knowledge of CPT, HCPCS and ICD-10 diagnosis codes.

Strong analytical skills, including the ability to analyze and organize data.

Strong attention to detail.

Excellent organizational, oral presentation and written and verbal communication skills

Proficiency in MS Office products, including PowerPoint, Excel, and Word

Wage Range: $26.00 to $30.00 per hour

Physical & Working Environment:

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

Must be able to travel when needed or required

Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)

Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate's state residency.