Medical Claims Examiner

Job DescriptionJob Title: Medical Claims ExaminerOverview:We are seeking a detail-oriented Medical Claims Examiner with 3-5 years of experience to review, evaluate, and process healthcare claims in accordance with plan guidelines, policies, and regulatory requirements. This role plays a key part in ensuring accurate and timely claims adjudication while maintaining compliance and high service standards.Key Responsibilities:Review and adjudicate medical claims for accuracy, completeness, and eligibility based on plan benefits and policiesApply appropriate coding knowledge (CPT, ICD-10, HCPCS) to ensure correct claim processingAnalyze claim documentation, including medical records, provider submissions, and billing statementsIdentify discrepancies, errors, or potential fraud/abuse and escalate as neededProcess adjustments, denials, and reprocessing requests in accordance with guidelinesMaintain productivity and quality standards while meeting turnaround time requirementsCollaborate with internal teams (e.g., customer service, provider relations) to resolve claim issuesEnsure compliance with HIPAA, regulatory requirements, and organizational policiesQualifications:3-5 years of experience in medical claims examination, adjudication, or processingStrong knowledge of healthcare claims workflows and medical terminologyFamiliarity with CPT, ICD-10, and HCPCS coding systemsExperience working with health plans, TPAs, or managed care organizations preferredHigh attention to detail and analytical skillsStrong communication and problem-solving abilitiesProficiency with claims systems and Microsoft Office applications Preferred Qualifications:Experience with high-volume claims processing environmentsExposure to Medicare, Medicaid, or commercial health plan claimsUnderstanding of MSO or provider-side claims workflows is a plusWork Environment:Fast-paced, detail-driven environment requiring strong organizational skills and the ability to manage multiple priorities effectively.All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.