Claims Examiner

Decton Staffing Services

Decton is currently recruiting for Claims Examiner’s for a company in Orange paying $18 an hour.  If you are interested please submit your resume and call/txt Yesenia 949-207-1005.

The Claims Examiner analyzes and processes claims. This position is responsible for following regulatory and internal guidelines in conjunction with CalOptima policies and procedures as they apply to claims adjudication. The Claims Examiner is responsible to adjudicate claims that require minimal research and problem solving. 1 – 2 years of health claims processing background. Knowledge of Medicare or MediCal processing line of business preferred. Examiner is expected to adjudicate tier one claim types with attention to detail in order that high quality standards are met. The challenge of consistently and accurately processing an increased volume of claims in a production environment is attainable with appropriate staffing levels. The return on the investment is that approval of this position will allow us to continue meeting regulatory compliance and timeliness requirements

Job Summary

This position is for responsible for analyzing, validating claim data elements and claims processing.  The incumbent is responsible for adhering to the regulatory and internal processing guidelines in conjunction with policies and procedures related to claims adjudication.

Position Responsibilities

  • §  Responsible for processing non-institutional claim types.
  • §  Performs thorough review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services.
  • §  Responsible for manually correcting system generated errors prior to final claims adjudication.
  • Processes claims based upon contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and policies and procedures.
  • Analyzes, validates Medi-Cal pricing, researches, adjusts and adjudicates claims, reviews services for accurate charges; utilizing current billing code sets, i.e. International Classification Diseases (ICD10 codes), Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference.
  • Responsible for validating eligibility and possible other health insurance coverage on the claim.
  • Alerts manager or supervisor of more complex issues that arise.
  • Process claim exception reports as assigned.
  • Other duties as assigned by management.



Possess the Ability To:

  • Meet and maintain established quality and production standards.
  • Work independently and as part of a team.
  • Develop and maintain effective working relationships with all levels of staff and providers.
  • Handle multiple tasks and meet deadlines.
  • Effectively utilize computer and appropriate software (i.e., Microsoft Office Suite and claims processing systems).


Experience & Education

  • High School graduate or equivalent required.
  • 1 year of experience processing on-line medical claims in a managed care and/or PPO/indemnity environment, billing environment or equivalent experience in a claims processing unit required.
  • Experience processing Medi-Cal claims preferred.
  • Experience that demonstrates solid customer service skills required.

Knowledge of:

  • Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPC) and ICD-10 codes.
  • Industry pricing methodologies, such as Resource- based Relative Value Scale, Medicare/Medi-Cal Fee Schedule, etc.
  • Medical terminology; benefit interpretation and administration.
  • Facets Processing System preferred or equivalent.
  • Medi-Cal guidelines and regulations.
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