Claims Examiner II and III

We currently have an outstanding opportunity for you as a: Claims Examiner

We have positions open for Claims Examiner II and Claims Examiner III, depending on job experience.


Working under the direction of the Claims Manager, this position is responsible for processing commercial professional and institutional claims received in a timely and accurate manner per department guidelines. This position also processes routine EDI claims files by reviewing, coding and inputting data into information system using standard policies, procedures and guidelines.

Here are a few of the Essential Job Functions:

Processes HMO claims on a daily basis per established guidelines for: Fee-for-service claims, Emergency claims, and Encounter based/capitated claims.

Determines and forwards for medical review ER Claims which do not meet pass through criteria.

Follows-up on all claims suspended for review until all claims are in a final status.

Adjudicates claims when manual adjudication is necessary.

Downloads EDI files from FTP site and runs through the scripting program.

Job Requirements
The preferred candidates will have the following experience and education:

High School Diploma or equivalent

Minimum of 2 - 3 years experience in Medical/Institutional claims processing within a medical group/IPA setting or relevant experience.

Familiar with computerized claims processing/transaction system and medical coding (CPT and ICD9).
Previous IDX experience a plus.

Our benefits for full-time personnel include medical, dental, vision, life insurances, PTO, Paid holidays, 401(a) and 401(k) plans, an Employee Assistance counselor, credit union, legal group, flexible spending account and more!