Job Description

Claims Examiner

Location: Whittier, CA

Specialty: Non-Clinical – Finance/Accounting

Shift: Day (5 x 8 Hours) 07:00 – 15:30

Positions: 5

Duration: 13 weeks

Key Requirements

• Experience: Minimum 2 years of claims adjudication in ambulatory, acute care hospital, HMO, or IPA environment.
• Education: High school diploma or GED (physical proof required if verification fails).

Mandatory:

• Must have claims reimbursement experience
• DOFR (Division of Financial Responsibility) experience required
• Must have processed lab claims

References: Will need professional references for submission.

Interview: Onsite interview required.

Position Summary

• The Claims Examiner reports directly to the Claims Manager and is responsible for the processing functions (operation, adjudication, and payment) of UB-92 and HCFA-1500 claims received from PHP affiliated medical groups and hospitals for HMO patients.

Skills & Knowledge

• Knowledge of payment methodologies for:
• Professional (MD)
• Hospital
• Skilled Nursing Facilities
• Ancillary Services
• Understanding of timeliness and payment accuracy guidelines for commercial, senior, and Medi-Cal claims.
• Knowledge of compliance issues related to claims processing.
• Ability to interpret provider contract reimbursement terms.
• Ability to identify non-contracted providers for Letter of Agreement consideration.
• Data entry skills and experience with office automation and managed care computer systems.

Additional Information

• RTO: Must be submitted at time of submittal – no exceptions.
• Orientation: Orientation time may differ from shift hours listed.

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