Claims Examiner II
Responsible for processing medical claims. Resolves complex, difficult or non-routine claims requiring special handling in accordance with established policy guidelines. Reviews and authorizes payment and final disposition of claims requiring adjustment and claims benefit determination for reinsurance qualification. Handles complex, difficult or non-routine incoming and outgoing telephone inquiries regarding claims status, benefit quotations, benefit determination and denial information. Interacts with IPAs, Medical Groups, Providers, Hospitals and Members. Responds to written inquiries received from the above-named groups.
Preferred qualifications for this position include:
Extensive knowledge of medical terminology, CPT, ICDA-9 and RVS codes
Solid working knowledge of insurances -- PPO, EPO, HMO, POS, Medicare, etc., plus extensive working knowledge HMO claims processing
Proficient use of CRT keyboard, 10-key adding machine and make mathematical calculations
Must possess excellent oral and written communication, and computer skills in a mainframe setting, knowledge of Microsoft Office (i.e., Excel, Microsoft Word, etc.) a plus
Must display a high level of flexibility and attention to detail
To exceed or be an outstanding producer, productivity should be greater or equal to 200 claims per day with no more than a 2% error rate
Two (2) years HMO claims processing experience in a managed care environment, preferably PMG/IPA setting within the last 3 years or any combination of education and/or experience which produces an equivalency
Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission of improving the health and wellbeing of each patient we serve.
About the organization you will serve:
Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita and Simi Valleys. The group began as a single medical practice over 90 years ago.
Facey is part of Providence, an integrated, not-for-profit network of hospitals, care centers, medical clinics, affiliated services and educational facilities across Alaska, California, New Mexico, Montana, Oregon, Texas and Washington.
We offer a full comprehensive range of benefits — see our website for details — http://www.providenceiscalling.jobs/rewards-benefits
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Claims
Location: California-Mission Hills
Req ID: 351706