Claims Examiner

Job Summary: The Claims Examiner is responsible for processing UB-92 and HCFA-1500 claims from affiliated medical groups and hospitals for HMO patients. This includes operation, adjudication, and payment functions, reporting directly to the claims manager.Location:Whittier, California, United StatesResponsibilities:- Process UB-92 and HCFA-1500 claims.- Perform claims adjudication and payment.- Identify non-contracted providers for Letter of Agreement consideration.- Data entry.- Interpret provider contract reimbursement terms.- Maintain knowledge of compliance issues related to claims processing.- Understand timeliness and payment accuracy guidelines for commercial, senior, and Medi-Cal claims.Required Skills & Certifications:- High school diploma or GED equivalent.- Minimum 2 years of claims adjudication experience in ambulatory, acute care hospital, HMO, or IPA environment.- Knowledge of payment methodologies for Professional (MD), Hospital, Skilled Nursing Facilities, and Ancillary Services.- Claims reimbursement experience.- DOFR (Date of First Receipt) experience.- Experience processing lab claims.Preferred Skills & Certifications:- Experience interpreting provider contract reimbursement terms.Special Considerations:- Onsite interview required.- RTO (Requested Time Off) must be submitted at the time of submittal.Scheduling:- Monday - Friday- 07:00am - 03:30pm- Orientation time may differ from shift times listed.