Claims Examiner III

Claims Examiner IIILocation: 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 permPosition 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 adjudicationProfessional claims — CMS-1500Facility claims — UB-04Provider contractsHealth plan contracts and benefitsCMS guidelinesMedicare and commercial claimsMedical policies and coding guidelinesCPT, HCPCS, ICD, and revenue codesDRG and APC reimbursement methodologiesComplex, high-dollar, pended, and adjusted claimsClaims pricing, denials, and payment determinationsKey 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.