Claims Examiner III

Claims Examiner III

Location: Pasadena, CA (Hybrid considered after training once performance expectations are consistently met) Schedule: Monday – Friday, 8 am – 5 pm Pay Rate: Up to $34.00 per hour, depending on experience Employment Type: Temp to perm

Position Overview: A healthcare IPA is seeking an experienced Claims Examiner III with advanced, hands-on claims examination and adjudication experience. Candidates must have direct experience independently reviewing, pricing, adjusting, and adjudicating complex professional and facility claims within a managed care, IPA, MSO, medical group, TPA, or health plan environment.

Required Experience With:

• Direct claims examination and adjudication
• Professional claims — CMS-1500
• Facility claims — UB-04
• Provider contracts
• Health plan contracts and benefits
• CMS guidelines
• Medicare and commercial claims
• Medical policies and coding guidelines
• CPT, HCPCS, ICD, and revenue codes
• DRG and APC reimbursement methodologies
• Complex, high-dollar, pended, and adjusted claims
• Claims pricing, denials, and payment determinations

Key Responsibilities:

• Review, research, price, adjust, and adjudicate complex healthcare claims.
• Determine whether claims should be paid, denied, pended, reduced, or adjusted.
• Apply provider contracts, benefit guidelines, medical policies, coding rules, and regulatory requirements.
• Process professional and facility claims accurately and within required timeframes.
• Identify coding, billing, pricing, contractual, or system issues affecting claim payment.
• Research and resolve claim discrepancies and exceptions.
• Maintain required quality, productivity, and accuracy standards.
• Follow HIPAA, CMS, compliance, and company claims-processing guidelines.

Qualifications:

• Several years of recent, direct healthcare claims examination and adjudication experience.
• Prior Claims Examiner III, Senior Claims Examiner, Advanced Claims Processor, Claims Auditor, or similar experience preferred.
• Strong knowledge of professional and facility claims.
• Ability to independently handle complex claims with limited supervision.
• Strong analytical, research, and problem-solving skills.
• Dependable, accurate, and able to meet production standards.