Job ID# 1008627 – Posted 2/24/2023 – Los Angeles, CA

The Claims Examiner II is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes: 
Processing claims for all lines of business. Process all claims type as needed. Monitoring itemized billings for excessive charges, duplications. Ensuring that all work meets quality guidelines and is performed within acceptable time frames. Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated. Meeting and exceeding performance measurements for Claim Examiners as required by the department to meet regulatory compliance. Assisting management with onsite training as needed. Assist Claims Examiner III as needed for special requests.

Ability to operate PC-based software programs or automated database management systems. 
Strong communication skills with excellent analytical and problem solving skills. 
Ability to self-manage in a fast-paced, detail-oriented environment. 
Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials (PDR, CPT, ICD-10, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge. 
Moderate knowledge of Microsoft Word and Excel.

At least 0-2 years of healthcare claims processing experience in a managed care environment.  
Previous Medi-Cal or Medicare claims processing experience and knowledge of AB1455 regulations

High School Diploma

Associate’s Degree

Please send your resume and any additional information to our recruitment team at recruitment@nexlogica.com