Lead Claims Examiner

The Lead Claims Examiner of Check Runs and Special Projects is responsible for ensuring that all check runs are performed in a timely manner ensuring compliance and use of designated parameters by Leadership.  The Lead Claims Examiner of Check Runs and Special Projects will also assist by processing medical claims in an efficient, cost-effective, and timely manner meeting all required guidelines and performs adjustments as necessary.  In addition, she will serve as back up to the other Leads in the department and will report to the Director of Claims.

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

Required Skills

• Working knowledge of claims regulatory timeframes/timeliness of payment.
• Working knowledge of medical terminology & RVS/CPT/RBRVS/ICD-9 codes
• Experienced with provider contract payment methodologies including but not limited to case-rates and stop-loss.
• Experience in EZCAP check run process.
• Excellent communication, problem solving, and decision-making skills coupled with the ability to work successfully in a team environment.
• Leads the Claims Department in conducting regularly scheduled check runs.

Required Experience

• Minimum two (2) years of experience in conducting check runs in EZCAP
• Knowledge of regulatory requirements (CMS, DMHC and DHS)
• High School Diploma or General Education Development (GED) required.