Medical Claims Examiner

Full job description

Job Overview

We are seeking a highly skilled Medical Claims Examiner to join our healthcare administration team. In this vital role, you will be responsible for reviewing, analyzing, and processing medical claims to ensure accurate and timely reimbursement from insurance providers. The ideal candidate will possess comprehensive knowledge of medical coding systems, billing procedures, and health insurance claim processing standards. Your expertise will directly contribute to the efficiency of our revenue cycle management and the accuracy of medical records documentation. This position offers an opportunity to work within a dynamic healthcare environment dedicated to delivering exceptional service and operational excellence.

Responsibilities

• Process, adjudicate, and pay UB-92 and HCFA-1500 claims received from affiliated medical groups and hospitals for HMO patients.
• Report directly to the Claims Manager.
• Identify non-contracted providers for Letter of Agreement consideration.
• Interpret provider contract reimbursement terms (desirable).
• Strong understanding of payment methodologies for Professional (MD), Hospital, Skilled Nursing Facilities, and Ancillary Services.
• Knowledge of compliance issues, timeliness, and payment accuracy guidelines for commercial, senior, and Medi-Cal claims.
• Data entry experience.
• Training and proficiency in basic office automation and managed care computer systems.

MUST HAVE:

• Education Verification: Must be able to provide a copy/picture of a High School Diploma, GED, or higher education degree upon submission.
• Claims Experience: 2+ years of dedicated Claims Processing and Reimbursement experience (must be explicitly detailed on your resume).
• Adjudication Expertise: Proven experience with the ADJUDICATION of UB-92 and HCFA-1500 claims.
• Specialized Healthcare Knowledge: Direct, hands-on experience working with DOFR (Division of Financial Responsibility) provisions.
• Claim Types: Demonstrated experience processing laboratory claims.

Shift Timing : 7AM-3:30PM

Weekly schedule: M-F

CH1

Pay: $28.00 - $30.00 per hour

Experience:

• dedicated Claims Processing and Reimbursement : 2 years (Required)

Work Location: In person