Institutional Claims Examiner

Description:

The Institutional Claims Examiner is responsible for the accurate, timely, and compliant adjudication of institutional (hospital/facility) medical claims in accordance with applicable HMO, Medi-Cal, Medicare, and Commercial contracts. This role ensures proper determination of financial responsibility among health plans, providers, and delegated entities, while adhering to California and federal regulatory requirements applicable to a healthcare Management Services Organization (MSO).

Requirements:

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training Minimum:

High School Diploma or equivalent.

Preferred:

Additional coursework or training in healthcare administration, medical billing, or managed care.

Experience Minimum:

Five years of managed care claims processing experience.

Preferred:

Two - three years of recent institutional/hospital claims experience involving Medicare, Medi-Cal, HMO, PPO, and Commercial products. Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position. Certification(s) Professional claims or medical billing certifications preferred. Skills, Knowledge & Abilities Advanced knowledge of institutional claims processing, including UB-04 and

CMS-1500

claim forms. Strong understanding of DRG, OPPS/APC, Ambulatory Surgery, and RBRVS reimbursement methodologies. Working knowledge of Medi-Cal, Medicare, and California managed care regulations, including prompt payment requirements. Proficiency with claims processing systems, third-party pricing software, and standard office applications (Microsoft Office). Strong analytical, problem-solving, and decision-making abilities. Excellent written and verbal communication skills; ability to read, write, and communicate effectively in English. Ability to manage multiple priorities in a fast-paced, deadline-driven environment. Demonstrated attention to detail and commitment to accuracy and compliance.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This role is primarily sedentary and requires the ability to sit for extended periods while performing work at a computer workstation. The position involves light physical activity, including the ability to lift up to 10 pounds and to bend, stoop, reach, and file materials as needed. The employee must be able to frequently use a computer, keyboard, and standard office equipment, and maintain focus, manage workload pressures, and meet deadlines in a professional healthcare office or remote work environment.

PAY RANGE

$31.00 - $36.00 / hourly