Health Claims Examiner

Position Summary

We are seeking an experienced Health Claims Examiner to process and manage medical claims with accuracy, efficiency, and strong attention to detail. This role is responsible for reviewing, adjudicating, and resolving a variety of healthcare claims while ensuring compliance with benefit plans, policies, and regulatory requirements. The ideal candidate brings deep claims expertise, strong analytical skills, and a service-oriented mindset.

Essential Job Functions

• Process paper and electronic professional, facility, ancillary, and out-of-state (Blue Card®) claims, including pay, deny, and pend determinations.
• Research, resolve, and adjust claims by correcting allowances, recovering overpayments, and reprocessing failed or previously paid claims.
• Apply detailed plan knowledge, including covered expenses, exclusions, coordination of benefits, and Medicare coordination.
• Review claims for fraud, waste, abuse, hospital-acquired conditions, Workers' Compensation, and Third-Party Liability; refer cases as appropriate.
• Identify claims requiring clinical review, obtain medical records, and refer cases to the Claims Manager.
• Communicate professionally with members and providers to resolve inquiries, follow up on pended claims, and complete corrections and adjustments.
• Provide backup support to Member Services and function as a Member Services Representative when needed.
• Meet established productivity, quality, and schedule adherence standards.
• Follow internal policies and procedures and participate in special projects or assignments as directed.

Required Knowledge, Skills & Experience

• High school diploma or GED required.
• Minimum of three- five years of recent health claims processing experience
• Experience processing group medical claims or healthcare benefits from a payer or provider perspective.
• Strong knowledge of medical terminology, billing practices, CPT, ICD-9/ICD-10, HCPCS, DRG, and revenue codes.
• Solid understanding of benefit plans, coordination of benefits, exclusions, and third-party liability.
• Strong analytical, organizational, and problem-solving skills with exceptional attention to detail.
• Proficiency with Windows-based computer applications and the ability to learn complex claims systems.
• Excellent written and verbal communication skills with a strong customer-service orientation.
• Ability to multitask, work under pressure, and collaborate effectively in a team environment.

Location: El Monte, CA
Work Schedule: Monday-Friday, 8:30 a.m. - 4:30 p.m.
Work Environment: Onsite
Parking: Provided
Pay Rate: $23-28 per hour

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.