Medical Claims Examiner
2 weeks ago
We are seeking a detail-oriented and experienced Medical Claims Examiner to join our team on a temporary basis. The ideal candidate will have prior experience processing medical claims, particularly in the HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) environments. As a Medical Claims Examiner, you will be responsible for reviewing, adjudicating, and processing medical claims in a timely and accurate manner, ensuring compliance with healthcare policies, regulations, and insurance protocols.
- Review, analyze, and process medical claims, ensuring accuracy and compliance with HMO/PPO policies and guidelines.
- Verify patient eligibility, benefits, and coverage details for claims processing.
- Evaluate medical necessity and confirm that services provided are covered under the patient's insurance plan.
- Resolve discrepancies and disputes related to claim denials or underpayments, working with providers and other stakeholders as needed.
- Communicate with healthcare providers, members, and internal departments to clarify claim information and resolve issues.
- Ensure timely and accurate claim adjudication within specified service level agreements (SLAs).
- Maintain up-to-date knowledge of HMO/PPO claim processing protocols, industry trends, and regulatory changes.
- Process claim adjustments, reprocessing, and refunds as necessary.
- Document all claims activity in the claims management system with attention to detail and accuracy.
- Collaborate with other departments to improve claims processes and enhance customer service.
- High school diploma or equivalent required; Associate's or Bachelor's degree in healthcare administration or related field preferred.
- Minimum of 2 years of experience in medical claims processing, with specific experience in HMO/PPO claim adjudication.
- Strong knowledge of healthcare insurance, medical terminology, billing codes (CPT, ICD-10, HCPCS), and claim processing systems.
- Familiarity with regulatory requirements (e.g., HIPAA, state-specific insurance laws) and payer/provider contract terms.
- Proficiency with claims management software and MS Office (Excel, Word, Outlook).
- Excellent attention to detail, problem-solving skills, and ability to prioritize tasks in a fast-paced environment.
- Strong verbal and written communication skills with the ability to work collaboratively with healthcare providers, internal teams, and members.
- Ability to work independently with minimal supervision and meet deadlines consistently.
- Familiarity with medical claims auditing, fraud prevention, and compliance a plus.
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. For unincorporated Los Angeles county, to the extent our customers require a background check for certain positions, the Company faces a significant risk to its business operations and business reputation unless a review of criminal history is conducted for those specific job positions.
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