Healthcare Claims Examiner

Healthcare Claims Examiner

Location: El Monte, California

Ultimate Staffing is actively seeking a dedicated Healthcare Claims Examiner to join their client's team in El Monte, California. This role focuses on ensuring the accurate adjudication and resolution of a broad range of medical claims while maintaining compliance with benefit plans, policies, and regulatory requirements.

Responsibilities

• Review and adjudicate paper and electronic claims, including professional, facility, ancillary, and out-of-state (Blue Card®) claims, determining whether to approve, deny, or pend.
• Research and resolve claim discrepancies, including making payment corrections, recovering overpayments, and reprocessing claims as needed.
• Interpret and apply benefit plan provisions such as covered services, exclusions, coordination of benefits, and Medicare guidelines.
• Evaluate claims for potential fraud, waste, abuse, Workers' Compensation, hospital-acquired conditions, and third-party liability; escalate issues appropriately.
• Identify claims that require clinical review, obtain supporting documentation, and refer cases to the Claims Manager.
• Communicate professionally with members and providers to resolve inquiries, follow up on pending claims, and implement corrections.
• Provide backup support for Member Services and assist in a representative capacity when necessary.
• Meet established productivity, quality, and turnaround standards.
• Adhere to internal policies and assist with special projects or departmental initiatives as assigned.

Qualifications

• High school diploma or GED required.
• Minimum of 3 years of recent experience in healthcare claims processing; 5+ years preferred.
• Experience handling medical claims within a payer or provider environment.
• Strong knowledge of medical terminology, billing practices, and coding systems, including CPT, ICD-9/ICD-10, HCPCS, DRG, and revenue codes.
• Solid understanding of benefit plans, coordination of benefits, exclusions, and third-party liability.
• Strong analytical and problem-solving skills with a high degree of accuracy and attention to detail.
• Proficiency with Windows-based systems and the ability to quickly learn new claims platforms.
• Excellent written and verbal communication skills with a customer-service orientation.
• Ability to manage multiple priorities, meet deadlines, and work effectively in a team setting.

Work Hours

Monday-Friday, 8:30 a.m. - 4:30 p.m., onsite in California.

This position offers a pay range of $23-$28 per hour, depending on experience. If you are a detail-oriented professional with a passion for healthcare and claims management, this opportunity with Ultimate Staffing Services' client could be an excellent fit for you.

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.