Department: UHC: Managed Care
The Claims Adjudicator Sr is responsible mentoring and training Claims Adjudicators. The Lead will also analyze and process professional and hospital HMO Risk claims in accordance with the managed care contract provisions in an accurate and timely manner. Responds to questions from other adjudicators and processors. Verifies system assigned risk pool determination in accordance with the Division of Financial Responsibility matrix. Assists Director in creating, reviewing, and enhancing policies and procedures governing full risk claims processing on an annual basis or as needed. Assists other adjudicators and/or examiners as needed in order to assure that claims are completed within standards. Performs other duties as needed.
Education and Experience: High School Diploma or GED required. Associate's Degree preferred. Minimum five years managed care claims processing experience with professional and/or institutional claims required.
Knowledge and Skills: Extensive experience in health insurance claims processing, HMO claims or managed care environment is required, in-depth knowledge of medical billing and coding, knowledge of health insurance, HMO and managed care principles. Claims Payment System including Claim Hierarchy Categories, CPT, ICD-10, HCPCS, UB-04. Knowledge in UB and HCFA-1500 Insurance Claims, reading and interpreting Contracts and DOFR. Understanding of all CMS guidelines and regulations in relation to Claims Processing and Payments. Able to read; write legibly; speak in English with professional quality; use computer, printer, and software programs necessary to the position (e.g., Word, Excel, Outlook, PowerPoint). Operate/troubleshoot basic office equipment required for the position; Able to relate and communicate positively, effectively, and professionally with others; work calmly and respond courteously when under pressure; collaborate and accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; manage multiple assignments effectively; organize and prioritize workload; work well under pressure; problem solve; recall information with accuracy; pay close attention to detail; work independently with minimal supervision. Able to distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens, and written documents necessary to the position.
Licensures and Certifications: Valid California Driver's License required at time of hire.
Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, excellence, humility, integrity, justice, teamwork and wholeness.
Loma Linda University Health’s story is one of hope. Our people strongly believe in the work of physical, mental, and spiritual healing. They are also committed to excellence, integrity, and teamwork. We are a faith-based academic medical center in Southern California’s Inland Empire, and since our establishment in 1905, we’ve been a local, regional, national, and international leader in education, clinical care, and research.
Our 18,000 talented healthcare team members work in our system’s six hospitals, providing whole-person, patient-focused care to more than 57,000 inpatients and over a million outpatients annually. Our passion is to bring hope to each patient and family who seeks our help during their most vulnerable moments in life.
U.S. News and World Report ranks Loma Linda University Medical Center as a Top Riverside/San Bernardino metro area hospital. LLU Children’s Hospital and LLU Medical Center — Murrieta are on the U.S. News list of Top Performing Hospitals for Maternity Care and the Newsweek list of Best Maternity Care Hospitals. Our Medical Center and Children’s Hospital nursing teams have also achieved the prestigious Magnet Status recognizing our strong commitment to nursing excellence.
Loma Linda University’s eight professional schools offer more than 100 academic programs designed to prepare thousands of skilled Christian healthcare workers for service in our local area and locations worldwide. Our graduates enter their careers with an intellectual curiosity and a strong foundation of the knowledge and skills needed for their chosen field. The Great Colleges to Work For program has named Loma Linda University as an outstanding place to work six of the last seven years, and has added the University to its Honor Roll of institutions three times.
