California Licensed Medical Claims Examiner

Job Summary

To support a dedicated healthcare team, the part-time California Licensed Medical Claims Examiner will ensure accurate and timely adjudication of CMS 1500 and UB-04 claims while working in a hybrid environment.

Key responsibilities

• Adjudicate medical claims in compliance with Medicare and Medi-Cal guidelines
• Review and analyze claims policies, procedures, and reimbursement methodologies
• Determine benefit and co-payment responsibilities for claims processing

Required qualifications

• Minimum of 2 years of medical claims payment experience in an HMO environment
• Solid knowledge of Medicare and Medi-Cal managed care claims processing
• Experience with CPT-4, ICD-10-CM, RBRVS, ASA, and HCPCS coding
• Familiarity with claims adjudication processes and NCCI rules
• Extensive working knowledge of reimbursement methodologies for professional claims