Claims Examiner

Decton Staffing Services


$16.00-19.00/HR DOE



Please let me know if you are interested, thanks




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 Company 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 Company contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and Co. 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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