Examine, review and process claims according to contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
Assess appropriateness of returned, denied, or paid claims by reviewing and following contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
Ensure claim timeliness processing standards are being met
Work alongside manager to establish and maintain claims processing rules that meet all regulatory and business requirements
Assist internal and external partners with questions related to claims decisions or claims statuses
Maintain a comprehensive understanding of claim processing guidelines at both the federal and state level

High School Diploma or Equivalency, professional experience may be substituted
Minimum of three (3) years of experience with processing, researching, and adjudicating claims in a complex managed care environment
Working knowledge of the health plan insurance industry and CPT/HCPCS procedure codes, and relevant federal and state regulations
Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee schedule, Diagnosis Related Groups (DRG), Multiple Procedure Payment Reduction (MPPR) and benefit interpretation and administration
In depth experience with Medicare and Medicaid claims processing
Demonstrated skills within Microsoft Office Applications & electronic claims processing systems
Strong organizational, analytical, communication, and time management skills

Medical insurance coverage (Medical, Dental, Vision)
Work/life balance – we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, sick time
Advancement opportunities
We’ve got a track record of hiring and promoting from within, meaning you can create your own path!
And additional benefits

Claims Examiner

Key skills