Claims Examiner III

New Leaf Staffing

Job Location:

Pasadena, TX - USA

Monthly Salary: USD 20 - 32

Posted on: 30+ days ago

Vacancies: 1 Vacancy

Job Summary

Claims Examiner III
Location: Pasadena CA (Hybrid considered after training once performance expectations are consistently met)
Schedule: Monday Friday 8 am 5 pm
Pay Rate: Up to $34.00 per hour depending on experience
Employment Type: Temp to perm

Position Overview
A healthcare IPA is seeking an experienced Claims Examiner III with advanced hands-on claims examination and adjudication experience.

Candidates must have direct experience independently reviewing pricing adjusting and adjudicating complex professional and facility claims within a managed care IPA MSO medical group TPA or health plan environment.

Required Experience With

Direct claims examination and adjudication
Professional claims CMS-1500
Facility claims UB-04
Provider contracts
Health plan contracts and benefits
CMS guidelines
Medicare and commercial claims
Medical policies and coding guidelines
CPT HCPCS ICD and revenue codes
DRG and APC reimbursement methodologies
Complex high-dollar pended and adjusted claims
Claims pricing denials and payment determinations

Key Responsibilities

Review research price adjust and adjudicate complex healthcare claims.
Determine whether claims should be paid denied pended reduced or adjusted.
Apply provider contracts benefit guidelines medical policies coding rules and regulatory requirements.
Process professional and facility claims accurately and within required timeframes.
Identify coding billing pricing contractual or system issues affecting claim payment.
Research and resolve claim discrepancies and exceptions.
Maintain required quality productivity and accuracy standards.
Follow HIPAA CMS compliance and company claims-processing guidelines.

Qualifications

Several years of recent direct healthcare claims examination and adjudication experience.
Prior Claims Examiner III Senior Claims Examiner Advanced Claims Processor Claims Auditor or similar experience preferred.
Strong knowledge of professional and facility claims.
Ability to independently handle complex claims with limited supervision.
Strong analytical research and problem-solving skills.
Dependable accurate and able to meet production standards.

Claims Examiner IIILocation: Pasadena CA (Hybrid considered after training once performance expectations are consistently met)Schedule: Monday Friday 8 am 5 pmPay Rate: Up to $34.00 per hour depending on experienceEmployment Type: Temp to permPosition OverviewA healthcare IPA is seeking an experie...

Direct claims examination and adjudication
Professional claims CMS-1500
Facility claims UB-04
Provider contracts
Health plan contracts and benefits
CMS guidelines
Medicare and commercial claims
Medical policies and coding guidelines
CPT HCPCS ICD and revenue codes
DRG and APC reimbursement methodologies
Complex high-dollar pended and adjusted claims
Claims pricing denials and payment determinations

Key Responsibilities

Review research price adjust and adjudicate complex healthcare claims.
Determine whether claims should be paid denied pended reduced or adjusted.
Apply provider contracts benefit guidelines medical policies coding rules and regulatory requirements.
Process professional and facility claims accurately and within required timeframes.
Identify coding billing pricing contractual or system issues affecting claim payment.
Research and resolve claim discrepancies and exceptions.
Maintain required quality productivity and accuracy standards.
Follow HIPAA CMS compliance and company claims-processing guidelines.

Qualifications

Several years of recent direct healthcare claims examination and adjudication experience.
Prior Claims Examiner III Senior Claims Examiner Advanced Claims Processor Claims Auditor or similar experience preferred.
Strong knowledge of professional and facility claims.
Ability to independently handle complex claims with limited supervision.
Strong analytical research and problem-solving skills.
Dependable accurate and able to meet production standards.