Claims Examiner

Overview The Claims Examiner is responsible for reviewing, analyzing, and adjudicating medical claims for a management services organization (MSO) supporting medical clinics and Independent Practice Association (IPA) groups. This role applies plan and contract rules, reimbursement methodologies, and medical billing/coding guidelines to ensure claims are processed accurately, timely, and in compliance with federal and California requirements. The Claims Examiner collaborates with Provider Relations/Network, Contracting, Utilization Management, Finance, Member/Patient Services, and Compliance to resolve pended claims, denials, adjustments, and provider disputes while meeting production and quality standards. Responsibilities The role involves reviewing, analyzing, and adjudicating medical claims; applying applicable rules and guidelines; resolving pended claims, denials, and adjustments; and collaborating with internal departments to ensure timely and accurate claim processing in compliance with regulatory requirements. Qualifications Education Minimum: High school diploma or equivalent, or equivalent combination of education and experience. Experience Minimum: Two years of healthcare claims processing or claims adjudication experience, including experience interpreting benefits and reimbursement rules. Experience working with claim denials, adjustments, and provider inquiries. Working knowledge of medical billing/coding basics (CPT, HCPCS, ICD-10, revenue codes) and how coding impacts adjudication. Experience using claims systems and/or EDI workflows preferred. Skills, Knowledge & Abilities Knowledge of end-to-end claims lifecycle including intake, edits, adjudication, pricing, payment, denials, adjustments, and recoveries. Ability to interpret provider contracts, fee schedules, and reimbursement methodologies (FFS, DRG/APC, capitation, bundled payments). Strong analytical and problem-solving skills; able to research discrepancies and determine appropriate resolution. Attention to detail and accuracy with ability to meet production, turnaround time, and quality standards. Effective written and verbal communication; professional customer service with providers and internal stakeholders. Working knowledge of HIPAA transactions (837/835) and claims-related regulatory requirements including prompt pay and dispute resolution. Proficient with claims systems, Microsoft Office/Google Workspace, and basic reporting tools. Physical, Mental & Environmental Requirements The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office or hybrid office environment and involves prolonged periods of sitting, computer use, and data review. The role requires sustained concentration, analytical thinking, and attention to detail to ensure claims accuracy and regulatory compliance. Occasional lifting of materials up to approximately 10–20 pounds may be required. The position may require extended work hours or weekend work to meet operational and regulatory deadlines. #J-18808-Ljbffr Lsmamso