Health Claims Examiner

Location: El Monte

Work Schedule & Location

• Hours: Monday-Friday, 8:30 a.m. - 4:30 p.m.
• Work Environment: Onsite
• Parking: Parking provided

Essential Job Functions

• Process paper and electronic professional, facility, ancillary, and out-of-state (Blue Card®) claims, including pay, deny, and pend determinations.
• Research, resolve, and adjust claims, including correcting allowances, recovering overpayments, and reprocessing failed or previously paid claims.
• Apply plan knowledge accurately, including covered expenses, exclusions, coordination of benefits, and Medicare coordination.
• Review claims for fraud, waste, abuse, hospital-acquired conditions, Workers' Compensation, and Third-Party Liability, referring cases as appropriate.
• Identify claims requiring clinical review, obtain medical records, and refer to the Claims Manager.
• Interact professionally with members and providers to resolve inquiries, follow up on pended claims, and complete corrections and adjustments.
• Provide backup support to Member Services and function as a Member Services Representative as needed.
• Meet productivity, quality, and schedule adherence standards.
• Follow internal policies and participate in special projects or assignments as directed.

Required Knowledge, Skills & Experience

• High school diploma or GED required.
• Minimum five (5) years of recent health claims processing experience; ten (10) years preferred.
• Experience processing group medical claims or healthcare benefits from a payer or provider perspective.
• Strong knowledge of medical terminology, billing practices, 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, organizational, and problem-solving skills with attention to detail.
• Proficiency with Windows-based computer applications and the ability to learn complex claims systems.
• Excellent verbal and written communication skills; strong customer service orientation.
• Ability to multitask, work under pressure, and collaborate effectively in a team environment.

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.