Senior Medical Claims Examiner

The Senior Claims Examiner administers health plan contracts by processing medical claims in an efficient, cost-effective, and timely manner meeting all required guidelines and performs adjustments as necessary. Some of the duties include handling of Third-Party Liability requests, Out-of-pocket Maximum requests, EDI rejects and other special projects.

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

• Computer and 10-key skills by touch;
• Knowledge of medical terminology, CPT/RBRVS/ICD-9 codes;
• Full understanding of HMO & capitation concepts and Medicare guidelines;
• Excellent communication skills;
• Ability to work independently and function under time deadlines.

Required Experience

Required:

• High school diploma or General Education Development, relevant experience in lieu of education will be considered
• Minimum two (2) years medical claims processing experience

Preferred:

• N/A