The Claim Adjuster is responsible for determining if an internal or external request for payment/denial reconsideration is accurate, appropriate and meets all regulatory requirements and health plan guidelines.
Process all adjustments based on departmental standards, regulatory requirements and health plan guidelines.
Consistently meet the timeliness standards set forth by CMS, DMHC, DHCS, health plans and departmental standards.
Determine and appropriately apply level of reimbursement based on established criteria; contracts, HMO contracts, reciprocity, etc.
Understand and interpret provider contracts and health plan Division of Financial Responsibility (DOFR).
Develop and maintain effective business relationships with internal and external clients.
Correspond with providers and inter-office departments to process and resolve adjustment requests.
Effectively handle special projects and member reimbursements within established departmental guidelines.
Produce and review weekly inventory reports on all pending adjustment requests and provide report to management.
Process all provider dispute resolution (PDR) requests based on CMS, DMHC requirements, health plan guidelines and departmental standards.
Perform check voids and full/partial refunds based on department standards.
