Job Type



3 days ago


Alhambra, CA


Job Description:

Claims Examiner will be responsible for adjudicating complex claims, manually and/or automatically priceclaims accurately, and identify billing issues.

Responsibilities include, but not limited to:

  • Analyze, research, and process and/or adjust claims with accurate use of procedures and ICD-9 codes under respective provider and member benefits based on:
    • Contractual agreement
    • Health Plan division of financial responsibility
    • Applicable regulatory legislature
    • Claims processing guidelines
    • Client group’s and company’s policies and procedures
  • Review and process facility (UB-04) and professional (CMS-1500) claims.
  • Process Medicare member claims based on DMHC and DHS regulatory legislature
  • Respond and resolve providers’ and health plans’ inquires in a timely manner
  • Review services for appropriate charges and apply authorization
  • Monitor aging claims with reports to maintain timeliness
  • Maintain quality and productivity standards
  • Participate in special projects
  • Works closely with Supervisor and reports any issues


•         Bachelor’s degree in related field or AA degree with related experience

•         Must have at least 3 years of applicable healthcare claims adjudication experience within a managed care industry

•         Must be familiar with ICD-9, HCPCS, CPT coding, APC, ASC, and DRG pricing.

•         Must be familiar with facility and professional claim billing practices.

•         Must have good written and communication skills.

•         Must be able to follow guidelines, multi-task, and work comfortably within a team-oriented environment.

•         Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and EZ-CAP. Crystal Report is a plus.

•         Typing skills of at least 40 wpm.