Health Claims Examiner in Los Angeles, California

Location

Los Angeles, California

Job Type

Full-time

Company

Ultimate Staffing

Ultimate Staffing is an established company seeking a health care claims examiner on a temp to hire basis. The role involves reviewing and processing health care claims, investigating and resolving claims issues, and communicating with members and providers.

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

Skills • 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

Company Overview • Ultimate Staffing specializes in clerical, administrative, customer service, and manufacturing and production positions. It was founded in 1994, and is headquartered in Orange, California, USA, with a workforce of 501-1000 employees. Its website is http://www.ultimatestaffing.com/.