Established company is seeking a health care claims examiner on a temp to hire basis in the greater Pasadena, CA area. Pay ranges from $23-27/hr DOE.

Responsibilities:

• Review and process paper and electronic professional, facility, ancillary, and out-of-state (Blue Card®) claims, including decisions to pay, deny, or pend.
• Investigate, resolve, and adjust claims by correcting allowances, recovering overpayments, and reprocessing failed or previously paid claims.
• Apply comprehensive plan knowledge accurately, including covered services, exclusions, coordination of benefits, and Medicare coordination.
• Examine claims for indicators of fraud, waste, abuse, hospital-acquired conditions, Workers' Compensation, and Third-Party Liability, escalating cases as appropriate.
• Identify claims requiring clinical review, request and analyze medical records, and submit cases to the Claims Manager.
• Communicate professionally with members and providers to address inquiries, follow up on pended claims, and complete necessary corrections or adjustments.
• Provide backup support for Member Services and perform Member Services Representative duties when needed.
• Consistently meet established productivity, quality, and schedule adherence requirements.
• Adhere to internal policies and procedures and participate in special projects or additional assignments as assigned.

Qualifications:

• High school diploma or GED required.
• Minimum of five (5) years of recent health claims processing experience.
• Proven experience processing group medical claims or healthcare benefits from either a payer or provider perspective.
• Strong working knowledge of medical terminology, billing practices, and coding systems, including CPT, ICD-9/ICD-10, HCPCS, DRG, and revenue codes.
• Thorough understanding of benefit plans, coordination of benefits, exclusions, and third-party liability.
• Excellent analytical, organizational, and problem-solving skills with keen attention to detail.
• Proficiency in Windows-based applications and the ability to quickly learn complex claims processing systems.
• Strong verbal and written communication skills with a customer-focused approach.
• Demonstrated ability to multitask, perform effectively under pressure, and collaborate within 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.