Claims Examiner

Lsmamso; San Bernardino (CA); On-site; USD 50,000 - 70,000; Full time

Job summary

A management services organization in California is seeking a Claims Examiner to review, analyze, and adjudicate medical claims. The ideal candidate will have at least two years of experience in healthcare claims, strong analytical skills, and knowledge of billing and coding standards. This role involves collaborating with various departments to ensure compliance and efficiency in processing claims, while maintaining high production and quality standards. The position may require occasional weekend work to meet deadlines.

Qualifications

• Minimum two years of healthcare claims processing experience.
• Working knowledge of medical billing/coding basics.
• Experience interpreting benefits and reimbursement rules.

Responsibilities

• Review, analyze, and adjudicate medical claims.
• Resolve pended claims, denials, and adjustments.
• Collaborate with departments for accurate claim processing.

Skills

Claims lifecycle knowledge

Analytical and problem-solving skills

Attention to detail

Effective communication

Knowledge of HIPAA transactions

Proficient with Microsoft Office

Education

High school diploma or equivalent

Tools

Claims systems

Google Workspace

Job description

Overview

The Claims Examiner is responsible for reviewing, analyzing, and adjudicating medical claims for a management services organization (MSO) supporting medical clinics and Independent Practice Association (IPA) groups. This role applies plan and contract rules, reimbursement methodologies, and medical billing/coding guidelines to ensure claims are processed accurately, timely, and in compliance with federal and California requirements. The Claims Examiner collaborates with Provider Relations/Network, Contracting, Utilization Management, Finance, Member/Patient Services, and Compliance to resolve pended claims, denials, adjustments, and provider disputes while meeting production and quality standards.

Responsibilities

The role involves reviewing, analyzing, and adjudicating medical claims; applying applicable rules and guidelines; resolving pended claims, denials, and adjustments; and collaborating with internal departments to ensure timely and accurate claim processing in compliance with regulatory requirements.

Qualifications

• Education
  Minimum: High school diploma or equivalent, or equivalent combination of education and experience.
• Experience
  Minimum: Two years of healthcare claims processing or claims adjudication experience, including experience interpreting benefits and reimbursement rules. Experience working with claim denials, adjustments, and provider inquiries. Working knowledge of medical billing/coding basics (CPT, HCPCS, ICD-10, revenue codes) and how coding impacts adjudication. Experience using claims systems and/or EDI workflows preferred.
• Skills, Knowledge & Abilities
  
  • Knowledge of end-to-end claims lifecycle including intake, edits, adjudication, pricing, payment, denials, adjustments, and recoveries.
  • Ability to interpret provider contracts, fee schedules, and reimbursement methodologies (FFS, DRG/APC, capitation, bundled payments).
  • Strong analytical and problem-solving skills; able to research discrepancies and determine appropriate resolution.
  • Attention to detail and accuracy with ability to meet production, turnaround time, and quality standards.
  • Effective written and verbal communication; professional customer service with providers and internal stakeholders.
  • Working knowledge of HIPAA transactions (837/835) and claims-related regulatory requirements including prompt pay and dispute resolution.
  • Proficient with claims systems, Microsoft Office/Google Workspace, and basic reporting tools.

Physical, Mental & Environmental Requirements

The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office or hybrid office environment and involves prolonged periods of sitting, computer use, and data review. The role requires sustained concentration, analytical thinking, and attention to detail to ensure claims accuracy and regulatory compliance. Occasional lifting of materials up to approximately 10–20 pounds may be required. The position may require extended work hours or weekend work to meet operational and regulatory deadlines.