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Claims Examiner II 

resume-library  |  United States  |  

United StatesUnited States (US)
Banking & Insurance/Insurance
Work Type:
Work Time:
Full Time


Claims Examiner II


A Claims Examiner is responsible for analyzing and the adjudication of medical claims as it relates to managed care. Performs payment reconciliations and/or adjustments related to retroactive contract rate and fee schedule changes. Resolve claims payment issues as presented through Provider Dispute Resolution (PDR) process or from claims incident/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payments. Generates and develop reports which include but not limited to root causes of PDRs and Incidents. Collaborates with other departments and/or providers in successful resolution of claims related issues.


Process medial claims, professional and institutional as it relates to the appropriate Federal and State regulations based on the member’s Line of Business; Medicare, Medi-Cal, Commercial, PACE Lines of Business.

Read and interpret DOFRs as it relates to the claim in order to ensure that group is financially at risk for payment.

Read and interpret provider contracts to ensure payment/denial accuracy.

Read and interpret Medi-Cal and Medicare Fee Schedules.

Correct claims payment/denial errors identified by the Claims Auditor prior to a check run.

Must maintain an error accuracy of under 3%.

Communicate with Claims Management for any issues relating to provider, fee schedule, eligibility, authorization, or system issues.

Assist in the creation of any business rules and training in order for the Claims Department to become more efficient and accurate.

Coordinate with the Recovery Department for any identified overpayments.

Attend monthly departmental meetings and provide feedback when requested.

Other duties as assigned.


HS Diploma or GED

3+ years of Claims Processing experience in a managed care environment.

Must be knowledgeable of Medi-cal regulations.

Preferred knowledge of Medicare and Commercial rules and regulations.

Knowledge of medical terminology.

Must have an understanding to read and interpret DOFRs and Contracts.

Must have an understanding how to read a CMS-1500 and UB-04 form.

Must have strong organizational and mathematical skills.