Sr. Medical Claims Examiner

Irvine, CA | Temporary

Job ID: [SA] Sr. Medical Claims Examiner Medicare Industry: Healthcare Pay Rate: $22.00-$25.00

We are looking for an experienced Sr. Medical Claims Examiner with excellent analyzing skills. YOU will be accountable for following regulatory and internal guidelines in conjunction with policies and procedures. YOU will also adjudicate more complex claims, requiring additional research or problem solving.

 Position Responsibilities

Responsible for accurate and timely adjudication of claims according to guidelines.

Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e. co-payments, deductibles, etc.

Claims processing based upon contractual and/or agreements, involving the use of established payment methodologies, Division of Financial Responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures.

Responds to incoming calls from providers of service in a timely and courteous manner.

Process both professional (CMS-1500) and facility (UB-04) claim types.

Maintain quality and productivity standards as set by management.

Resolve provider or physician group (network) claims inquiries and apply resolution in a timely fashion.

Responds to questions from examiners. Explains processing guidelines and internal processes when needed.

Review services for appropriateness of charges and apply authorization guidelines during claims processing.

Prepare written requests to providers; follow up and handle completion of claim for returned correspondence.


Keep up to date with Medi-Cal billing policies as well as OHC and Medicare polices

Assist provider (inpatient and outpatient), claims processing issues in a detailed analysis structure

Responsible for making continuous changes and updates as a workbook author and updating PowerPoint presentations (such as implementing ICD-10)

Promoting the use of electronic claims submissions / EHR (Electronic Health Records)

Document all provider contacts in contact management system

Respond to questions from the client concerning provider issues

Solid knowledge of State Healthcare/Medi-Cal



We will consider for employment all qualified Applicants, including those with Criminal Histories, in a manner consistent with the requirements of applicable state and local laws , including the California Fair Employment and Housing Act (FEHA).

Medical Claims & Adjudication is a requirement for this position

Ability to commit to three (3) month minimum and willing to extend as needed- potentially to six (6) month or more

High School graduate or equivalent.

2-3 years experience processing on-line claims in a managed care and/or PPO/indemnity environment.

Experience processing Medicare or Medi-Cal claims

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