Claims Examiner III

Schedule/Shift
(6a-9a)-(3p-6p)

Role Insights

-This role of the Claims Examiner III is considered an essential position within the organization
as well as the Claims Department. The Claims Examiner is responsible for collaborating with the
Claims Team to meet productivity goals as well as ensure quality. This candidate should possess
claims knowledge, prioritizing skills, and the ability to multi-task. This is not a routine position
as it requires energy, enthusiasm, and the capability to be a valuable resource and team player to
the entire Claims Team.

Primary Responsibilities
- Audit claims processing quality, develops, maintains and runs standard reports
- Assist the Claims Supervisor/Director in reviewing the quality auditing
tracking/reporting (financial and procedural)
- Coordinating with various departments to resolve disputes or issues
- Maintain the Claims department workflow
- Review and process hospital claims and complicated claims to assist claims examiners I,
and II
- Claims processing to ensure quality (in/out patient hospital claims, Medi-cal, Commercial, and Medi-care claims)
- Review auto adjudication of claims
- Review carve-outs in the Division of Financial Responsibility (DOFR)
- Review and process reports and work with management and claims unit
- Assist the Claims Manager in reviewing the quality auditing tracking/reporting
- Assist with training/supporting the claims team
- Recommend and assist in the development of process improvements
- Coordinating with various departments to resolve disputes or issues
- Able to process a claim and assist the team by answering questions and providing
support
- Prepare for check runs
- Other duties may be assigned as needed to assist the AMM team

Required Skills and Abilities
- High School Diploma or GED, some college preferred
- 3-5 yrs of claims examiner experience processing professional and facility claims
- Strong analytical skills and problem solving skills are necessary
- Know the industry guidelines for all LOBs
- Proficient with medical terminology, CPT, Revenue codes, ICD-10,
- Medicare and Medi-Cal claims adjudication experience required
- Knowledge of claims processing rules, managed care benefits and adjudication
- Strong analytical skills and problem-solving skills are necessary
- Familiarity with Medicare guidelines and ICE compliance guidelines
- Experience with the handling of claims in a managed care business (HMO)
- Extensive knowledge of claims processing and claims data analysis
- Experience with EZ-Cap and Encoder Pro preferred
- Must be familiar with Microsoft Office (Word, Excel, Outlook)
- Must possess a positive attitude, have excellent communication skills and is able to meet
deadlines in a fast-paced environment
- Must work well under pressure and deadlines


Selling Points:
Lots of company and career growth opportunity.

Weekly Pay

Medical, Dental, Vision Benefits

PTO

3-5 Must Have Skills/Qualifications:
Medicare/MediCal Experience in Claims


Schedule/Shift
(6a-9a)-(3p-6p)