Claims Examiner

Claims examiners review claims after they are submitted to ensure claimants and adjusters followed proper guidelines. They may assist adjusters with complicated claims or when, for example, a natural disaster occurs and the volume of claims increases.

Claims Examiner Job Description Template

Our company is looking for a Claims Examiner to join our team.


  • Provide backup for other examiners within the Department;
  • Ability to evaluate policy language and apply to claim;
  • Adhere to organizational Policies and Procedures;
  • Adjudicate claims in accordance with departmental policies and procedures and other rules applicable to specialty claims;
  • Meets production standards of 100-150 Hospital claims per day and 200-250 IPA claims as established by claims management;
  • Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines;
  • Requests additional information or follow up with provider for incomplete or unclean claims;
  • Conduct internal and external presentations;
  • Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims;
  • Adjudication of Commercial and Medicare Advantage claims;
  • Complete special projects as needed or requested;
  • Ability to make phone calls to Provider/Billing offices when necessary based on department guidelines;
  • Applicable regulatory legislature;
  • Requires general understanding of liability and damage assessment skills;
  • Ability to effectively communicate with External and Internal teams to resolve claims issues.


  • Basic knowledge of Microsoft Office Outlook, Word and Excel;
  • ICD-9 and ICD-10 and CPT-4 coding knowledge preferred;
  • Maintain regular attendance based on agreed-upon schedule;
  • Good, basic Mathematical skills a plus;
  • Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers;
  • Experience in a managed care environment preferred;
  • Ability to abide by Molina‚Äôs policies;
  • Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA);
  • Good working knowledge of the 10 key bad as well as the main keyboard;
  • Good verbal and written communication skills;
  • General knowledge of PC;
  • High School Diploma or GED Equivalent;
  • Must be detail oriented and have the ability to work independently.