Claims Examiner

Job Posting

Contract role. Contract to hire potential for the right candidate! The claims examiner reports directly to the claims manager. They are primarily responsible for the processing functions (operation, adjudication, and payment) of UB-92 and HCFA-1500 claims that are received from PHP affiliated medical groups and hospitals for HMO patients.

Education / Experience / Training :

High school graduate or equivalent required

Minimum of 2 years claims adjudication related experience in ambulatory, acute care hospital, HMO, or IPA environment

Knowledge of payment methodologies for : Professional (MD), Hospital, Skilled Nursing Facilities, and Ancillary Services

• Knowledge and understanding of timeliness and payment accuracy guidelines for commercial, senior and Medi-Cal claims
• Knowledge of compliance issues as they relate to claims processing

Experience in interpreting provider contract reimbursement terms desirable

Ability to identify non-contracted providers for Letter of Agreement consideration

Data entry experience

Training on basic office automation and managed care computer systems

COVID vaccine is required.