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Department:  Business Services
Status:  Full Time
Shift:  1st

Claims Examiner

Job Summary: 

The claims examiner is responsible for the accurate and timely administration of claim payments for services rendered by all healthcare providers (professional, facility, ancillary).  Supporting initiatives in improving efficiency, the claims examiner will meet and consistently maintain production, accuracy, and timeliness standards in claims processing. 


Essential Functions

  • Process medical claims meeting key metrics on productivity, financial accuracy, and regulatory compliance
  • Confirm patient eligibility and apply Coordination of Benefits guidelines by partnering with the Enrollment and Eligibility team
  • Interpret and administer member benefits, contract terms with medical providers, utilizes various fee schedules and payment terms (FFS, case rates, exclusions, carve-outs, capitation, per diems, stop loss, etc.) and health plans/Division of Financial Responsibility.  Forward claims that fall under the health plan risk
  • Review claims in pending status and request additional information required to resolve unclean or contested claims
  • Administer timely filing guidelines for contracted and non-contracted providers rejecting claims submitted untimely and reviewing proof of timely filing documentation from providers
  • Apply regulatory and industry guidelines in claims adjudication including timely processing, clear and concise language, required communication to providers and patients
  • Interacts in a positive and collaborative manner.  Alert the claims management team of issues and trends observed in the claim adjudication process
  • Resolve requests from providers, patients, and health plans on claims questions or issues
  • Support the claims team in implementing initiatives in improving claims processing efficiency
  • Perform other duties as assigned

Claims Examiner, Senior

  • Specialize in processing complex claim types and contracts that require careful review and a higher degree of accuracy
  • Assist in resolving escalated issues from provider customer service, member services, health plan, and other customers including making and answering phone calls to providers/billing offices when necessary based on team guidelines
  • Assist in completing special projects related to provider and plan JOCs, system upgrades, etc.
  • Mentor on the team that leads aspects of training function
  • Subject matter expert in a variety of knowledge sets and process improvement activities
  • Perform other duties as assigned



Education, Training and Experience


Required: High School Diploma or equivalent, 2 years of experience in a medical claims processing environment, knowledge of HMO/managed care regulatory guidelines

Senior: 5 years of medical claims processing experience

Preferred: Experience with Epic Tapestry system


Skills or Other Qualifications



Strong moral compass and commitment to Hoag’s values

Motivated to learn, continually improve and operate to one’s fullest potential

Positive attitude, passionate, excited, strong desire to simplify processes.

Experience in providing excellent customer service, empathetic ability

Skills to multi-task and manage competing priorities, apply critical thinking to solve problems

Tech-savvy and possess a capability to quickly learn new applications

Ability to maintain composure and compassion while addressing a high volume of competing tasks

Comfortable with ambiguity and open to collaborative environments

Microsoft Word, Excel, Typing/Data Entry

Strong working knowledge of regulatory guidelines in managed care (Title 22, AB1455, AB1203, AB1324, AB72, CMS guidelines, COB guidelines, etc.)


License and Certifications




Nearest Major Market: Orange County
Nearest Secondary Market: Los Angeles

Job Segment: Clinic, Medical, EMR, Law, Compliance, Healthcare, Legal

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