Claims Examiner

Job Summary: The Claims Examiner is responsible for processing UB-92 and HCFA-1500 claims from affiliated medical groups and hospitals for HMO patients. This includes operation, adjudication, and payment functions, reporting directly to the claims manager. Location:Whittier, California, United States Responsibilities: - Process UB-92 and HCFA-1500 claims. - Perform claims adjudication and payment. - Identify non-contracted providers for Letter of Agreement consideration. - Data entry. - Interpret provider contract reimbursement terms. - Maintain knowledge of compliance issues related to claims processing. - Understand timeliness and payment accuracy guidelines for commercial, senior, and Medi-Cal claims. Required Skills & Certifications: - High school diploma or GED equivalent. - Minimum 2 years of claims adjudication experience in ambulatory, acute care hospital, HMO, or IPA environment. - Knowledge of payment methodologies for Professional (MD), Hospital, Skilled Nursing Facilities, and Ancillary Services. - Claims reimbursement experience. - DOFR (Date of First Receipt) experience. - Experience processing lab claims. Preferred Skills & Certifications: - Experience interpreting provider contract reimbursement terms. Special Considerations: - Onsite interview required. - RTO (Requested Time Off) must be submitted at the time of submittal. Scheduling: - Monday - Friday - 07:00am - 03:30pm - Orientation time may differ from shift times listed. - Duration: 13 weeks

Created: 2026-03-10