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Retro-Adjudication Representative

Administrative | Emeryville, CA | Full Time, Contract, and Temporary

Job Description

Retro-Adjudication Representative 761302 

The Retro-Adjudication Team is responsible for the billing, registration and AR of all government and commercial, contract and managed care payers.  The unit deals regularly with complex policy and procedural issues that involve regulations with coverage and billing in regards to Medicare, Medi-Cal, CCS, HMO, PPO, and Covered CA payers and the coverage structure for new and existing AR.  It is the units’ responsibilities to communicate and to coordinate throughout various Medical Center departments, including the billing agents to ensure the quality of the university billing process. Within this unit, the Retro-Adjudication Representatives are responsible for correction of government and commercial, contract and managed care new and existing accounts receivables for MGBS clients.  The incumbent demonstrates the ability to perform all aspect of billing and registration with quality.  The incumbent’s main task is to resolve all registration and difficult coverage issues through constant communication with the payers (by phone or via web access), other MGBS units, clinical departments and billing agents and patients/guarantors.


  • Corrections of Accounts in Retro-Adjudication WQ and PB Charge Review WQ
  • Examines and evaluates accounts for appropriate registration and coverage.
  • Verification of erred RTE responses in PB Charge Review
  • Assign visits with the correct primary coverage and update unposted charges
  • Timely filing of PB Charge Review charge sessions in keeping with  lag day goals
  • Correction of registration errors made by frontend and backend staff.
  • Clarification of primary coverage – working with the regulations of Medicare and Medi-Cal as well as contractual DOFR set-up.
  • Review of entire AR of account to assure that all billing has been made to the correct payor in the correct order.
  • Interpret account information and enter important details to provide an audit trail for follow up and patient. 
  • Research payments received in regards EOB (Explanation of Benefits), APEX and Health Logic to confirm correct primary payment.
  • Review of non-payment and/or incorrect payment for possible registration and coverage.  
  • This may include, but is not limited to the use of the following reference tools and guidelines:
    • RTE response
    • Payor Website
    • EOB Information
    • APeX Follow-up Notes and SBO Notes
    • CMS Coverage Guidelines
    • Medi-Cal Eligibility Tool
    • Analyze Explanation of Benefits (EOBs) for accurate posting of rejection, adjustment and other posting requirements needed in APEX.
  • Perform Charge Corrections when cleaning-up charges billed in error.
  • Balancing payments of paid services not posted correctly
  • Retrieve all required information needed in order to evaluate correct credit balance and/or correct refund payee.
  • Effectively communicate with MGBS peers, payers, patients,  departments Leads, Assistant Managers and managers. 
  • Utilize knowledge of various systems including, but not limited to:
    • Microsoft Word, EXCEL, Outlook, APEX, Payor Web Portals, Health Logic, government and/or non-government websites, and any other information systems which would be required for insurance eligibility, benefit verification or other information needed during detailed follow-up.
    • Perform Special Projects or Other Duties as Assigned by the Manager
    • Attend monthly meetings and unit and team meetings aimed at increasing knowledge.
  • Other Retro-Adjudication Duties May include:
    • Secure guarantor/patient demographic and /or insurance information as required.
    • Process correspondence as required in accordance with departmental procedures.
    • Billing or rebilling corrected claims.
    • Notify manager of possible procedural change for improving efficiency.


  • At least 2 years of previous Insurance billing experience.
  • Demonstrate the Ability to communicate effectively (orally and written).
  • Experience with MS EXCEL and OUTLOOK
  • Ability to work independently or as needed with a team.
  • Proven ability to coach and mentor staff for optimal results
  • Demonstrate the ability to perform all aspects of Retro Review with superior quality.
  • Excellent Attendance Record.
  • Problem-Solving skills

$28 per Hour        Emeryville, CA 94608        10 Month Assignment