Claims Examiner

The Claims Examiner will be responsible for researching and resolving pending claims, reviewing claim denials requiring manual review, and ensuring timely processing in compliance with policies, procedures, and regulatory guidelines. The role involves determining claim payments, maintaining correspondence for procedural and medical coding, and adhering to all regulatory standards.

Duties and Responsibilities

• Review, price, and release paper and electronic claims for assigned claim types.
• Analyze Manual Review and Master Denial reports for all company health programs.
• Audit claims from specialized reports (e.g., ER, Family Planning, Mental Health).
• Identify and propose process improvements or automation in collaboration with the Supervisor.
• Contribute ideas for System Change Forms (SCFs) as needed.
• Stay updated on company health policies and support departmental improvement initiatives.
• Ensure compliance with all regulatory guidelines.
• Maintain a daily activity log.
• Assist in claims processing and report billing/error trends identified during reviews.
• Adhere to AB1455 Claims Settlement Practices and DHCS Regulations timelines.
• Perform additional duties and projects as assigned.

Skills/Knowledge/Abilities

• Familiarity with the Medi-Cal program.
• Experience in a high-volume production environment.
• Strong oral and written communication skills.
• High attention to detail.
• Knowledge of medical terminology and/or coding is highly preferred.

Education and Experience

• High school diploma or equivalent.
• Prior experience as a claims examiner.