Claims Examiner

Posted · Add Comment


  • 20-00022
  • Full Time/Contract
  • Recruiting
  • Pasadena, CA
Job Description
Our client is an innovative network of providers delivering innovative and quality care to patients from Northern to Southern California.

Medical Claims Examiner

Pasadena, CA

The Medical Claims Examiner/processor is responsible for adjudicating medical claims from providers billing Medicare and Medicaid. Duties & responsibilities include but not limited to; the accurate and timely adjudication of paper and/or electronically formatted claims received in the CMS 1500 and/or UB-92 format. This person processes all claims and applicable claims correspondence in accordance with Medicare and Medi-Cal regulatory guidelines, contract provisions and established policies and procedures. Additionally, he/she is responsible for consistently meeting accuracy and productivity targets outlined in the department’s performance standard. Quality Assurance and Productivity Standards and HIPAA rules must always be adhered to.


  • Review pricing methodology for multiple plans
  • Ensures compliance with all applicable Federal, State and/or County laws and regulations related to our documented guidelines and processes
  • Maintains compliance with all company policies and procedures
  • Processes claims by entering patient, payment and provider information timely and accurately from a UB or CMS claim form
  • Identify and correct any and all duplicate or corrected claims received
  • Adjudicate claims with a high level of productivity (average 150 claims per day) and minimum average accuracy levels (Procedural accuracy of 97.0% and Financial accuracy of 97.0%) in accordance with all departmental standards
  • Claims payment
  • Analyzing medical insurance claims for possible claim errors
  • Complete other tasks, as assigned
  • Answer and respond to internal and external emails in a professional and courteous manner.
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in Company’s policies and procedures relating to HIPAA compliance


  • High School Diploma or equivalent required
  • Minimum of 2-year’s medical claims payment experience in an HMO environment (i.e. MSO, IPA or health plan)
  • Strong knowledge of Medicare and Medi-Cal managed care claims processing and compliance guidelines.
  • Experience with CPT-4, ICD-9CM, ICD-10CM, RBRVS, ASA and HCPCS as well as in depth understanding of Medicare and Medi-Cal guidelines that apply to COB and Medicare Secondary Payer.
  • Working knowledge of reimbursement methodologies of professional claims including injectable drugs. Must be detail-oriented, attentive, organized, and able to follow directions.
  • Ability to work independently utilizing company established processes.
  • Ability to meet deadlines and maintain department quality standards.
  • Ability to interact well with providers calling regarding claim status.
  • Ability to interact well with fellow employees and supervisors and be ateam player.
  • Strong work ethics and professionalism.
  • Ability to quickly adapt and gain a sound understanding of claims system
  • Intermediate computer skills including Microsoft Word, Excel and Internet navigation.


  • Full-Time/Contract/Non-Exempt
  • $18.00/hr – $22.00/hr


Your Details

Please fill in the form below to send us brief details about you. We will use this information to get in touch to process your application in full.

Basic Details

First Name*

Last Name*

Contact Information

Email Address*

Phone Number

Mobile Phone Number

Supporting Comments

Please provide a short summary in support of your application for this vacancy.


Attach Resume

Please attach a copy of your CV (.doc, .docx, .pdf)