Claims Examiner III

4 weeks ago


Long Beach, United States Advanced Medical Manage Full time
Job DescriptionJob Description

Role Insights

This role of the Claims Examiner III is considered an essential position within the organization as well as the Claims Department. The Claims Examiner is responsible for collaborating with the Claims Team to meet productivity goals as well as ensure quality. This candidate should possess claims knowledge, prioritizing skills, and the ability to multi-task. This is not a routine position as it requires energy, enthusiasm, and the capability to be a valuable resource and team player to the entire Claims Team.

Primary Responsibilities

  • Audit claims processing quality, develops, maintains and runs standard reports
  • Assist the Claims Supervisor/Director in reviewing the quality auditing tracking/reporting (financial and procedural)
  • Coordinating with various departments to resolve disputes or issues
  • Maintain the Claims department workflow
  • Review and process hospital claims and complicated claims to assist claims examiners I, and II
  • Claims processing to ensure quality (in/out patient hospital claims, Medi-cal, Commercial, and Medi-care claims)
  • Review auto adjudication of claims
  • Review carve-outs in the Division of Financial Responsibility (DOFR)
  • Review and process reports and work with management and claims unit
  • Assist the Claims Manager in reviewing the quality auditing tracking/reporting
  • Assist with training/supporting the claims team
  • Recommend and assist in the development of process improvements
  • Coordinating with various departments to resolve disputes or issues
  • Able to process a claim and assist the team by answering questions and providing support
  • Prepare for check runs
  • Other duties may be assigned as needed to assist the AMM team


Required Skills and Abilities

  • High School Diploma or GED, some college preferred
  • 3-5 yrs of claims examiner experience processing professional and facility claims
  • Strong analytical skills and problem solving skills are necessary
  • Know the industry guidelines for all LOBs
  • Proficient with medical terminology, CPT, Revenue codes, ICD-10,
  • Medicare and Medi-Cal claims adjudication experience required
  • Knowledge of claims processing rules, managed care benefits and adjudication
  • Strong analytical skills and problem-solving skills are necessary
  • Familiarity with Medicare guidelines and ICE compliance guidelines
  • Experience with the handling of claims in a managed care business (HMO)
  • Extensive knowledge of claims processing and claims data analysis
  • Experience with EZ-Cap and Encoder Pro preferred
  • Must be familiar with Microsoft Office (Word, Excel, Outlook)
  • Must possess a positive attitude, have excellent communication skills and is able to meet deadlines in a fast-paced environment
  • Must work well under pressure and deadlines



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