Job Description
Insight Global is looking for a Claims Examiner to work for a Non Profit in Orange County, CA. This position would be onsite for training for 1 month and then has the potential to go FULLY remote, or hybrid. In this position, you will be responsible for the investigation, determination, and reporting of claims processing through auditing billing
processes, including pre and post-billing activity. The Examiner will audit, conduct root cause analysis, identify
issues and propose solutions to correct and prevent recurrence; he/she will assist management with
implementation of measures to ensure claim processing and payment accuracy, and adherence to all applicable
policies, standards, and regulations internal and external to the organization. Monitors and reviews appeals
processing of assigned account(s).
1. Supports the quality assurance process by routinely auditing claims and claim processing activity. Reviews
claims for irregularities, accuracy, completeness and/or other criteria; and related processes to ensure proper
guidelines, procedures and techniques have been followed.
2. Prior to submitting claim data to vendor for processing, the Examiner performs quality assurance review of
designated claims following established auditing procedures; such reviews include but are not limited to
verification of authorization for services provided, values entered in the system such as coding, data
discrepancies, duplicate records. Documents and communicatesfindings, and escalates issues when necessary.
3. Coordinates with billing vendor for oversight, investigation, and resolution activities; while working closely with
internal team and supervisor. Routinely monitors provider contracted services from a quality assurance point
of view to ensure vendor is adhering to contractual obligations, agreed upon procedures, and adequate
performance. Analyzes reports and metrics of billing activity, identifies issues, gaps and inconsistencies;
documents and reports findings and recommends solutions to immediate supervisor and management.
4. Reviews department and overall revenue cycle processes to identify technical, operational, and cost reduction
improvement opportunities on an ongoing basis and as assigned; including but not limited to: coding accuracy,
benefit payment, contract interpretation, and compliance with policies and procedures. Makes
recommendations to management and assists in the implementation of approved solutions.
5. Assist supervisor with EHR system related tasks such as testing of new features, contract configuration
validation, and other related duties.
6. Assists with developing training materials (related to claim quality, workflow processes, policies and
procedures) and participates in effective training, guidance and coaching of new hires, entry level examiners,
and external parties such as provider network.
7. Corresponds with vendors, network providers, insurance carriers, and team members, as necessary, soliciting
and coordinating required information to complete or resolve specific actions related to billing processing,
payments, appeals, resolution of issues, and operational improvement activities.
8. Monitors and reviews claim denials, no response, and underpayments for assigned insurance carrier or
accounts. Reviews, investigates, and corresponds with vendor to identify and resolve issues to ensure payment
from insurance companies; creates solutions to reduce appeals
9. Creates and maintains records, specialized reports, and metrics of audits. Maintains detailed documentation,
including methods and techniques selected for reviewing, analyzing and evaluating claims and claim
processing; additionally, keeps record of identified issues, recommended solutions, and status of issue
resolution.
10. Supports the analysis of revenue and monetary discrepancies, and other ad-hoc analysis as required.
11. Assists in internal and external audits and other ad hoc projects as required.
12. Maintains positive and strong working relationships with insurance carriers, network providers, vendors, and
internal teams to ensure collaborative relationships, quality assurance activities, and issue resolution.
13. Maintains a strong knowledge of revenue cycle concepts and processes, latest developments, advancements
and trends, as it relates to claim management and EHR systems, to allow her/him to easily identify, research,
and resolve claim processing issues, and expedite payment from carriers.
Required Skills & Experience
2 + years of hospital claims experience (Examiner, Auditor, Processor)
2-3 years of healthcare experience
Microsoft Excel experience
High School Diploma
Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.