Claims Examiner

Description 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. Requirements 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. #J-18808-Ljbffr LSMA Management, Inc.