Claims Examiner jobs in Santa Ana, CA

Claims Examiner reviews, evaluates, and processes insurance claims and makes recommendations for resolution. Examines and authorizes insurance claims investigated by insurance adjusters. Being a Claims Examiner studies reports prepared by adjusters and similar claims to determine the extent of insurance coverage and validity of the claim. Communicates with agents, claimants, and policy holders. Additionally, Claims Examiner determines settlement according to organization practices and procedures. May require a bachelor's degree. Typically reports to a supervisor or manager. The Claims Examiner work is closely managed. Works on projects/matters of limited complexity in a support role. To be a Claims Examiner typically requires 0-2 years of related experience. (Copyright 2024 Salary.com)

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Claims Examiner II
  • MemorialCare Medical Foundation
  • Fountain Valley, CA FULL_TIME
  • Claims Examiner II

    - (MEM007743)
    Description


    Title:
    Claims Examiner II

    Location: Fountain Valley

    Department: Claims

    Status: Full-Time

    Shift: Days (8hrs)

    Pay Range: $22.41/hr - $32.50/hr

    At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. Memorial Care stands for excellence in healthcare. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.


    Position Summary

    The Claims Examiner II accurately reviews, researches and analyzes professional, ancillary and institutional inpatient and outpatient claims.

    Essential Functions and Responsibilities of the Job

    • Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines.
    • Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims.
    • Comprehensive knowledge of various fee schedules and CMS prices for outpatient/inpatient institutional, ancillary and professional claims, including, but not limited to Medicare fee schedules, DRG, APC, ASC, SNF-RUG.
    • Ability to identify and report processing inaccuracies that are related to system configuration.
    • Process all types of claims, such as, HCFA 1500, outpatient/inpatient UB92, high dollar claims, COB and DRG claim.
    • Reviews. processes and adjudicate claims for payment accuracy or denial of payment according to Department’s policy and procedures.
    • Processes all claims accurately conforming to quality and production standards and specifications in a timely manner.
    • Documents resolution of claims to support claim payment and/or decision.
    • Makes benefit determinations and calculations of type and level of benefits based on established criteria and provider contracts.
    • Understands and interprets health plan Division of Financial Responsibilities and contract verbiage.
    • Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines.
    • Adjudication of Commercial and Medicare Advantage claims.
    • Ability to prioritize, multitask and manage claims assignment within department goals and regulatory compliance and with minimal supervision.
    • Ability to make phone calls to Provider/Billing offices, when necessary, based on department guidelines.
    • Requests additional information or follow up with provider for incomplete or unclean claims.
    • Ability to effectively communicate with External and Internal teams to resolve claims issues.
    • Ability to interact in a positive and constructive manner.

    Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there’s more...Check out our MemorialCare Benefits for more information about our Benefits and Rewards.


    Qualifications


    Experience

    • Minimum of 5 years’ experience in processing all types of professional, ancillary and institutional claims in Managed Care.
    • Comprehensive knowledge of various fee schedules and CMS pricers for professional, facility and ancillary claims.
    • Comprehensive knowledge of CPT, ICD-9 and ICD-10 codes, inpatient procedure coding, HCPCS, Revenue Codes, medical terminology and COB required.
    • Working knowledge of Claims Information systems.
    • Understands division of financial responsibility for determination of financial risk.
    • Type a minimum of 45 words per minute.

    Education

    High School diploma

  • 15 Days Ago

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Fingerprint Examiner (Part-Time)
  • City of Santa Ana
  • Santa Ana, CA PART_TIME
  • The City of Santa Ana is looking for individuals who are results-oriented, possess great attitude, demonstrate creativity and innovation, work efficiently, show a record of success and have a passion ...
  • 1 Day Ago

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Claims Processor
  • Hansen and Adkins Auto Transport
  • Los Alamitos, CA FULL_TIME
  • With nearly three decades of continuous growth and no signs of slowing down, Hansen & Adkins Auto Transport, Inc. (“H&A”) is dedicated to providing high quality, cost-effective vehicle transportation ...
  • 18 Days Ago

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Claims Specialist
  • Illumination Foundation
  • Santa Ana, CA FULL_TIME
  • “Every person deserves compassion, dignity, and the safety of a place to call home.”Homelessness is the largest social and public health crisis in California. Illumination Foundation (IF) is a growing...
  • 23 Days Ago

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Claims Processor
  • Robert Half
  • Los Alamitos, CA OTHER
  • A leader in the automotive transport industry is seeking a claims processor to join their operations immediately. ResponsibilitiesEnters & process new and existing claims in the database.Checks basic ...
  • 6 Days Ago

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Claims Coordinator
  • Collectors
  • Santa Ana, CA FULL_TIME
  • Collectors is the leading creator of innovative technology that provides value-added services for collectors worldwide. We grade, authenticate, vault and sell millions of record-setting collectibles, ...
  • 16 Days Ago

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0 Claims Examiner jobs found in Santa Ana, CA area

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Senior Claims Examiner Workers Compensation - Hybrid
  • Sedgwick
  • Pasadena, CA
  • Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A c...
  • 3/28/2024 12:00:00 AM

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Claims Adjuster
  • MedPOINT Management
  • Los Angeles, CA
  • Job Description Job Description Summary The claims adjuster is responsible for the adjusting of claims, in accordance wi...
  • 3/27/2024 12:00:00 AM

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Legal Claims Rep
  • Manpower
  • El Segundo, CA
  • Our client, Legal Industry is seeking a Claims Examiner to join their team. As a Legal Claims Examiner you will be part ...
  • 3/27/2024 12:00:00 AM

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Claims Processor
  • vTech Solution, Inc.
  • Whittier, CA
  • Status: Open Union Code: Profession: Non-Clinical - Finance/Accounting Specialty: Claims Processor Unit: Claims Examiner...
  • 3/27/2024 12:00:00 AM

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Insurance Agent
  • HealthMarkets
  • Irvine, CA
  • HealthMarkets Overview If youre looking for an exciting opportunity where you can change peoples lives and achieve finan...
  • 3/26/2024 12:00:00 AM

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Claims Manager
  • Call the Car
  • Diamond Bar, CA
  • Job Description Job Description BASIC JOB PURPOSE: The Claims Manager is to oversee the daily operations of the claims d...
  • 3/25/2024 12:00:00 AM

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Senior California Workers' Compensation Claims Examiner | Remote
  • KING'S INSURANCE STAFFING LLC
  • Los Angeles, CA
  • Our client, an A Rated Insurance Carrier, is seeking to add a Remote - Senior California Workers' Compensation Claims Ex...
  • 3/24/2024 12:00:00 AM

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Claims Auditor
  • Innovative Management Systems Incorporated
  • La Puente, CA
  • Job Type Full-time Description THE POSITION. This position is responsible for reviewing and processing claims, including...
  • 3/24/2024 12:00:00 AM

Santa Ana /ˌsæntə ˈænə/ (Spanish for "Saint Anne") is the county seat and second most populous city in Orange County, California in the Los Angeles metropolitan area. The United States Census Bureau estimated its 2011 population at 329,427, making Santa Ana the 57th most-populous city in the United States. Santa Ana is in Southern California, adjacent to the Santa Ana River, about 10 miles (16 km) from the coast. Founded in 1869, the city is part of the Greater Los Angeles Area, the second largest metropolitan area in the United States, with almost 18 million residents in 2010. Santa Ana is a ...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Claims Examiner jobs
$53,271 to $70,643
Santa Ana, California area prices
were up 2.5% from a year ago