CLAIMS EXAMINER JOB DESCRIPTION

Adjudicating a health insurance claim is a precise act. Every decision this role makes - pay, deny, pend, or escalate - carries regulatory weight under CMS and DMHC guidelines and a direct financial consequence for members and providers alike. The Claims Examiner owns adjudication of professional, institutional, and ancillary claims across commercial, Medicare Advantage, and Medicaid lines of business, applying CPT, ICD-10, and fee schedule logic within a production environment that measures accuracy at 98.5% or above. Few individual contributor roles in managed care combine this level of technical coding knowledge with daily compliance accountability at volume.

As the Claims Examiner, you are accountable for adjudicating health plan claims accurately and within regulatory timeframes, directly affecting member access to benefits and the organization's financial integrity. You will operate within the claims operations department, collaborating with provider contracting, medical management, and compliance teams to resolve pends, correct processing errors, and meet client performance guarantees.

Career Impact: Mastery of Medicare Advantage adjudication rules and CMS pricing methodology, including DRG, APC, and ASC fee schedules, builds a specialization that commands premium value across managed care organizations.

Business Impact: Accurate, timely adjudication reduces downstream audit exposure and protects claim payment accuracy rates for health plan clients who depend on clean, compliant claims output.

Growth Opportunity: Examiners who demonstrate proficiency across commercial and government lines routinely advance into claims lead, auditor, or utilization review roles with broader technical authority.

Company Value: Roles in this group offer remote or hybrid work arrangements with company-provided technology, reflecting a mature operational model built for distributed claims teams.

• Adjudicate professional, institutional, and ancillary claims across commercial, Medicare Advantage, and Medicaid lines in accordance with CMS and DMHC guidelines.
• Review and resolve claim holds and pends by researching eligibility, coverage, and provider contract terms to reach a compliant payment or denial determination.
• Validate CPT, ICD-10, HCPCS, and Revenue Code accuracy on submitted claims, identifying unbundling, duplicate billing, and coding discrepancies before final adjudication.
• Calculate benefits using applicable fee schedules, including Medicare DRG, APC, ASC, and SNF-RUG, and provider contract agreements to ensure payment accuracy.
• Document claim determinations, notes, and resolution rationale in the claims processing system with accuracy sufficient to support internal and external audits.
• Coordinate with provider relations, medical management, and compliance teams to resolve complex pends and communicate required system updates.
• Monitor assigned claim inventory daily, prioritizing pended and outlier claims to meet production and timeliness standards within departmental goals.
• Escalate coverage disputes, potential fraud indicators, and system configuration errors to leads or supervisors with documented findings.

• Bachelor's degree in health administration, business, or a related field, or equivalent work experience.
• 3 or more years of claims adjudication experience in a managed care or health insurance environment, with demonstrated knowledge of professional and institutional claim types.
• Comprehensive knowledge of CPT, ICD-9/ICD-10, HCPCS, and Revenue Codes, including inpatient procedure coding and COB rules.
• Working knowledge of CMS and DMHC guidelines governing commercial and Medicare Advantage claims adjudication.
• Ability to read and apply provider contracts, fee schedules, and Division of Financial Responsibility language to payment determinations.
• Strong analytical skills with demonstrated accuracy in a high-volume production environment.
• Effective written and verbal communication skills for interaction with providers, internal teams, and external auditors.
• Ability to prioritize, multitask, and manage a claims inventory with minimal supervision while meeting regulatory and client timeliness requirements.

• Comprehensive knowledge of Medicare fee schedules, including DRG, APC, ASC, and SNF-RUG pricing methodologies for institutional and ancillary claims.
• Experience adjudicating Medicaid or Medi-Cal claims, including eligibility validation and CCS coordination.
• Familiarity with HIPAA privacy standards and PIPEDA requirements as applied to claims data handling.
• Fellowship of Life and Health Claims (FLHC) certification or active pursuit of an AIC or CPCU designation.

• Claim payment accuracy rate, targeting 98.5% or above per pay period as the primary production standard.
• Claims processed per hour or per day, measured against departmental production goals for direct-entry and scanned claim types.
• Pend resolution cycle time, reflecting how quickly held claims are researched and adjudicated to a final determination.
• Audit error rate on adjudicated files, measured during internal and external audit reviews for coding and payment compliance.
• Timeliness rate for benefit notices and payment processing, tracking adherence to regulatory and client SLA requirements.
• Typical tools: Claims processing systems (commonly TriZetto/QNXT or similar); medical coding references (commonly encoder software paired with ICD-10 and CPT codebooks).

• Base Salary Range: $45,000 to $72,000 annually, depending on seniority and line of business complexity
• Bonus: Performance-based bonus of 5% to 10% tied to accuracy and productivity metrics
• Equity: Typically not offered at this level in managed care operations roles
• Health Benefits: Medical, dental, and vision coverage; employer contribution varies by plan tier
• PTO: 15 to 20 days annually, plus standard federal holidays
• Common Perks: Remote or hybrid work options, tuition reimbursement, and professional certification support

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Employment in this role is contingent upon successful completion of a background check, which may include verification of prior employment and criminal history screening consistent with applicable law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, genetic information, veteran status, or any other characteristic protected under federal, state, or local law. Reasonable accommodations are available to qualified individuals with disabilities upon request throughout the application and employment process. Candidates must be authorized to work in the United States.

The Claims Examiner owns adjudication and financial management of Accident and Health claims, including Critical Illness, AD&D, and Weekly Accident Indemnity, ensuring coverage determinations and case reserves align with corporate policy and federal regulations. Working with insureds, brokers, physicians, and legal counsel, this role delivers accurate claims outcomes that protect the organization's financial position and support benefit policy utilization reporting.

Key Responsibilities

• Manage new and existing Accident & Health claims, including Critical Illness, AD&D, Weekly Accident Indemnity, medical, and other claim types.
• Investigate, confirm coverage, evaluate, and conduct reporting and documentation of complex claims in accordance with established guidelines.
• Conduct thorough investigations through contact with insureds, claimants, policyholders, brokers, other carriers, physicians, and lawyers.
• Coordinate independent assessments, field visits, and rehabilitation activity as appropriate.
• Review and interpret available coverage, recognizing policy exclusions and applying facts of loss.
• Determine and obtain required documentation to support claims in accordance with company policy and federal, provincial, and local regulations.
• Issue claim payments on a timely basis and establish case reserves reflective of corporate policy.
• Prepare summaries and files for litigation, mediation, arbitration, and multidisciplinary assessments.
• Manage and negotiate claims through the dispute resolution process where applicable.
• Prepare all mandated reports in a professional and timely manner.
• Engage with internal customers to provide detailed overviews of claim trends, loss experiences, and benefit policy utilization.
• Assist in development of training programs.

Required Qualifications

• 5 or more years of experience handling Accident and Health claims.
• Knowledge of medical and insurance terminology.
• Experience handling claim files in litigation.
• Familiarity with case law developments and their application within the relevant jurisdiction.
• Ability to understand and interpret complex insurance contracts and legislative changes.
• Strong analytical, problem-solving, investigative, and decision-making skills.
• Advanced written and verbal communication skills, including the ability to explain processes and terms clearly.
• Good negotiation and interpersonal skills; bilingual in English and French is an asset.
• Ability to travel as needed.

Embedded within the claims operations department, the Claims Examiner processes and adjudicates medical claims accurately against departmental policies, state standards, and accreditation requirements, maintaining a production rate of 31 claims per hour at 98.5% accuracy. Working alongside fellow examiners and department leadership, this role sustains the integrity of member and provider records while upholding strict confidentiality standards across all claim files and reports.

Core Functions

• Process claims accurately and efficiently.
• Review all incoming claims to verify necessary information.
• Determine that correct member and provider records are selected and utilized to process claims.
• Enter claims data and information into the claims processing system.
• Maintain all required documentation of claims processed and claims on hand.
• Adjudicate claims in accordance with departmental policies, procedures, state and accreditation standards, and other applicable rules.
• Meet production standards, including processing an average of 31 claims per hour with an accuracy rate of 98.5% over each pay period.
• Verify data of scanned paper claims at stated standards.
• Provide backup support for other examiners within the department.
• Maintain confidentiality of all claim files, reports, and related issues.

Qualifications & Experience

• High school diploma required.
• Experience processing medical claims, with knowledge of medical billing terminology and coding strongly preferred.
• 6 months of data entry experience with 10-key and word processing, with a minimum of 10,000 keystrokes per hour required.
• Proficient in MS Office.
• Ability to organize, prioritize, multitask, and manage time effectively.
• Capable of maintaining accuracy and productivity in a changing, work-from-home environment.
• Strong analytical skills with the ability to develop effective solutions and apply constructive feedback.
• Demonstrated ability to interact in a positive, respectful manner and maintain cooperative working relationships.
• Excellent listening and interpersonal communication skills.
• Ability to exercise strict confidentiality in all matters.

Reporting to department leadership, the Claims Examiner processes standard to moderate claims, including COB, across commercial, Medicaid, and Medicare product lines while meeting production and quality standards. Partnering with internal teams during backlogs and client-facing initiatives, this role contributes to client satisfaction and operational continuity by resolving holds and maintaining mail date integrity.

Primary Duties

• Participate in training programs as available or requested.
• Assist other departments during periods of backlogs.
• Participate in team meetings and contribute ideas and suggestions to ensure client satisfaction and promote teamwork.
• Process batch edit errors in accordance with designated standards.
• Maintain employee and insured confidentiality.
• Work overtime as required per business need.
• Identify areas of concern that may compromise client satisfaction.
• Maintain mail date integrity.
• Process standard to moderate claims, including COB, in accordance with company policies and timeliness standards while meeting or exceeding production and quality goals.
• Resolve outstanding holds in accordance with designated standards.
• Prioritize and complete all assigned tasks effectively.

Skills & Qualifications

• High school diploma or equivalent required.
• 1 year of claims processing experience or equivalent education preferred.
• Understanding of medical terminology, ICD-9, and CPT coding required.
• Knowledge of commercial, Medicaid, and Medicare products.
• Working knowledge of COB (Coordination of Benefits) preferred.
• Proficient in MS Office and general PC skills.
• Strong organizational, interpersonal, and communication skills.
• Ability to maintain designated production and quality standards.

Sitting at the intersection of technical quality assurance and claims operations, the Claims Examiner applies business knowledge to conduct targeted audits, identify data errors, and maintain technical reference materials within London Insurance Market service levels. Operating across internal teams and external colleagues, this role advances consistent quality outcomes by resolving problems independently and supporting more experienced staff on complex matters.

Duties

• Apply technical and business knowledge to perform targeted quality audits and identify potential data errors in the claims system.
• Work with technicians to correct any errors identified.
• Update or review technical reference materials.
• Ensure high standards of quality are achieved in line with customer and market expectations.
• Develop and maintain technical knowledge to efficiently complete work.
• Seek assistance from more experienced employees when handling complex matters.
• Manage time and productivity effectively within established guidelines and service levels.
• Resolve problems using independent judgment where possible.

Requirements

• Willing to learn about London Insurance Market practices and procedures.
• Proficient in Microsoft Office applications, including Word, Excel, and Outlook.
• Strong written and verbal communication skills.
• Strong organizational and personal management skills.
• Good analytical and problem-solving skills.
• Ability to work independently and as part of a team.
• Ability to build productive relationships with a variety of internal and external colleagues.
• Adaptable and supportive of change initiatives.

A key member of the claims team, the Claims Examiner reviews incoming claims, determines applicable coverage and benefit amounts, and communicates decisions to customers by letter, email, or telephone. Collaborating across departments to verify information and resolve discrepancies, this role shapes the customer experience at every touchpoint by delivering empathetic, timely, and accurate claim outcomes.

Functions

• Review claims, identify the incident, determine coverage in accordance with the contract, and conclude what benefit applies and the amount to be reimbursed.
• Pay or reject claims in accordance with the terms and conditions of the insuring agreement.
• Deliver a high standard of service and empathy when following up with customers by letter, email, or telephone.
• Answer incoming telephone or email inquiries from customers regarding the status of their claim.
• Document claim determinations and relevant notes into the claims management system in accordance with company guidelines.
• Collaborate with other departments to verify or obtain missing information.
• Research discrepancies accurately and escalate questionable claims to the manager.
• Send out claim forms to new customers as needed.

Position Requirements

• High school diploma or equivalent required.
• 1 to 2 years of experience in a customer service-related function.
• Previous claims experience preferred.
• Strong customer-first mentality and approach.
• Committed to integrity and transparency.

Accurate claim file management and technical documentation depend on the Claims Examiner, who conducts insurance documentation checks, liaises with customers and brokers, and manages multiple files within an agreed handling authority. Based within the claims adjusting team, this role advances process improvement projects and delivers training to recruits while supporting colleagues on complex technical matters.

Accountabilities

• Conduct technical checks on insurance documentation to ensure accuracy, using claims management systems to support the technical adjusting process.
• Liaise with customers and brokers to resolve queries and issues related to claims being adjusted.
• Manage multiple claim files within an agreed handling authority.
• Input details into the database to initiate settlements and updates.
• Complete accurate reporting associated with claims being adjusted.
• Support team members and customers with complex technical issues.
• Provide training to team members and recruits.
• Support and contribute to innovation and process improvement projects.

Experience & Qualifications

• Excellent customer service skills and experience, including listening, communication, and empathy.
• Strong negotiating and influencing skills.
• Positive attitude with a natural curiosity to identify improvements.
• Organised with good time management.
• Ability to calmly and confidently handle difficult situations.
• Strong ability to work under pressure and exceed targets.
• Ability to work as part of a team and represent the organization professionally.

As the Claims Examiner, this role delivers adjudication of health, dental, and vision claims in compliance with PIPEDA and HIPAA, serving as a subject matter expert for all claims-related matters within a travel insurance organization. The work directly supports the assistance and finance teams through daily operational collaboration and inbound and outbound member communication, enabling the organization to meet revenue, cost, and client implementation objectives.

What You'll Do

• Process health, dental, and vision claims.
• Adjudicate claims according to various benefit policies.
• Provide excellent customer service for claims matters both in person and via written correspondence.
• Help the claims team problem-solve and use sound judgment to proactively address and resolve problems.
• Work closely with assistance, finance, and other internal teams on day-to-day operations.
• Ensure all work complies with PIPEDA and HIPAA.
• Support department initiatives that increase revenues, reduce costs, and meet company objectives.
• Participate in client implementations and projects where required.
• Act as a subject matter expert for all claims-related matters.
• Handle inbound and outbound calls to members and health providers as required.

Minimum Qualifications

• 3 or more years of relevant claims processing experience required.
• Experience in the travel insurance industry required.
• Experience processing health, dental, and vision claims.
• High level of proficiency in Microsoft Office.
• Superior verbal and written communication skills.
• Strong time management and organizational skills.

Claims Examiner leads investigation, documentation, and resolution of liability, property, cargo, brokerage, and subrogation claims by gathering and analyzing claim data to establish legal responsibility and drive settlement and recovery outcomes. Reporting to department management and collaborating with internal customers, external vendors, and third parties, this role builds organizational resilience by identifying process improvements and applying best practices for third-party referral decisions.

Key Deliverables

• Investigate, document, manage, and resolve liability, property, cargo, brokerage, and subrogation claims, including those involving alleged vehicle defects.
• Gather and analyze claim data and evaluate facts to determine legal responsibility and accountability for settlement and recovery.
• Resolve coverage disputes.
• Respond to all related requests, including tenders to the customer's insurance carrier and requests for production of documents.
• Guide internal and external customers and third-party vendors on claims-related issues.
• Evaluate whether third-party intervention or referral is needed using established best practices.
• Identify process improvements.

Background & Experience

• 1 to 3 years of experience in insurance claims handling preferred.
• Customer service experience is a plus.
• Computer skills in Access, Excel, Word, Outlook, and internet research.
• Proficient written and verbal communication and presentation skills.
• Excellent negotiation skills with the ability to make fact-based decisions on time.
• Ability to multitask and manage competing priorities.
• Independent thinker and self-starter with the ability to work autonomously.
• Willingness to travel as necessary and work the required schedule.

The Claims Examiner owns prompt examination, investigation, damage evaluation, and payment of property insurance claims at semi-medium to semi-high complexity levels, exercising independent judgment within a designated authority. Reporting to claims management and working within established policies, this role shapes customer outcomes by maintaining accurate reserves and communicating coverage decisions clearly throughout each claim.

Role Responsibilities

• Analyze and manage claims by verifying coverage and gathering pertinent information to determine exposure.
• Maintain well-developed action plans for appropriate and timely resolution in accordance with established policies and procedures.
• Recognize and properly address coverage issues, potential fraud, and subrogation potential.
• Calculate and assign timely and appropriate reserves to claims and monitor reserve adequacy throughout the claim.
• Conduct detailed damage and bill reviews and control claim expenses.
• Pay and process claims within designated authority level or deny payments where no coverage, liability, or compensability exists.
• Enter claim payments and reserves into the claims management system with concise and accurate file documentation.

Education & Experience

• Associate degree or equivalent experience required.
• Bachelor's degree with a 3.0 cumulative GPA or higher preferred.
• Texas Adjuster License or demonstrated progress toward achieving the license required.
• AIC or CPCU designation preferred.
• 2 or more years of experience examining P&C Residential Property claims required, with 3 or more years preferred.
• Can communicate decisions clearly and professionally.

Embedded within a managed healthcare claims operation, the Claims Examiner produces adjudication decisions on professional and hospital claims, authorizations, and referrals for payment or denial in accordance with contract agreements and county, state, and federal regulations. Working closely with supervisors, internal departments, and the training team, this role advances department production by communicating problems, supporting audit preparation, and conducting proactive outreach to providers and members.

Job Functions

• Analyze claim holds and pends across all lines of business, researching and tracking required information to adjudicate professional and hospital claims.
• Conduct proactive or responsive outreach to providers, members, and other customers via phone, email, or other methods as needed.
• Provide input to supervisors and the training team regarding educational tools to enhance department production and processes.
• Communicate with internal departments to resolve claims issues promptly.
• Assist in preparing materials for external audits as needed.
• Communicate problems and trends to leads and management.
• Understand and apply county, state, and federal regulations.

Knowledge, Skills & Abilities

• High school diploma or GED required.
• 3 or more years of claims adjudication experience required.
• Customer service experience required.
• Knowledge of managed healthcare claim processing and medical regulations.
• Ability to apply procedures and methods used in claims adjudication without direct supervision.
• Strong analytical and interpretive skills with the ability to work independently.
• Basic PC skills required, including working knowledge of Microsoft Word.
• Ability to understand and meet customer needs in a claims setting.

Reporting to claims management, the Claims Examiner refines claim determinations by evaluating policyholder information, verifying eligibility, processing payments, and investigating moderate to highly complex claims within individual authority parameters. Partnering with internal teams and external claimants, this role delivers timely resolution of demand letters and settlements while maintaining strict confidentiality over sensitive insurance and beneficiary records.

Day-to-Day Responsibilities

• Conduct correspondence related to client requests for information.
• Evaluate available information to validate claims.
• Verify policyholder information, policy effective dates, premium status, and claim eligibility.
• Identify the need for additional information and contact the appropriate source to obtain it.
• Verify beneficiary or claimant information if a claim is warranted.
• Identify payment amounts and obtain required management approvals for payment.
• Process payments.
• Investigate moderate to highly complex claims, determine the level of resolution, advise claimants of status, and assist in negotiating settlement.
• Receive demand letters, research and investigate claims, respond within individual parameters, and escalate as appropriate.

Professional Experience

• High school diploma or GED required.
• Fellowship of Life Health Claims (FLHC) Certification preferred.
• 4 or more years of insurance or claims processing experience required.
• Experience working with insurance and medical terminology.
• Knowledge of appropriate claims processing procedures and documentation.
• Good analytical and problem-solving skills.
• Strong interpersonal, communication, and negotiation skills.
• Must maintain confidentiality of sensitive material.
• Ability to work effectively in a team environment.

As the Claims Examiner, this role oversees review, documentation, and fraud monitoring of life and annuity claims by analyzing incoming information, corresponding with claimants, medical providers, and law enforcement, and maintaining regulatory compliance. The claims and legal team relies on this work to ensure contested claims are thoroughly investigated and that all correspondence and findings are accurately recorded for compliance purposes.

Scope of Work

• Analyze information and documentation received to determine how to proceed with a claim review and identify methods of obtaining additional information from alternative sources.
• Review claims and outside sources used in the review.
• Document correspondence and conversations.
• Correspond verbally and in writing with claimants, medical providers, medical examiners, and law enforcement.
• Work closely with management, legal counsel, medical director, claims assistants, and other departments to gather information for contested claims.
• Monitor claims for fraud and take appropriate action, including engaging the fraud team or conducting additional research.
• Maintain compliance with regulations.

Education & Experience

• Associate's degree in a business field or equivalent experience required.
• 2 years of claims experience required.
• Good understanding of life and annuity product language, provisions, and regulatory and compliance rules and regulations.
• Excellent communication and customer service skills.
• Strong organizational, problem-solving, and analytical skills.
• Ability to cross-train and learn other products.
• Ability to multitask and adapt to change.

A key member of the managed care claims team, the Claims Examiner adjudicates all claim types, including HCFA 1500, UB92, COB, and DRG claims, applying comprehensive knowledge of CPT, ICD-10, HCPCS, and CMS guidelines to ensure payment accuracy and regulatory compliance across commercial and Medicare Advantage lines. Collaborating across provider contracting, billing offices, and internal operations, this role maintains production and quality standards with minimal supervision while accurately interpreting fee schedules and Division of Financial Responsibilities to protect the organization against processing inaccuracies.

Performance Expectations

• Process all types of claims, including HCFA 1500, outpatient and inpatient UB92, high-dollar claims, COB, and DRG claims.
• Adjudicate claims for payment accuracy or denial in accordance with departmental policies and procedures.
• Process all claims accurately and in conformance with quality and production standards on time.
• Document resolution of claims to support payment decisions.
• Make benefit determinations and calculate the type and level of benefits based on established criteria and provider contracts.
• Understand and interpret health plan Division of Financial Responsibilities and contract language.
• Determine out-of-network and out-of-area service providers and process in accordance with company and governmental guidelines.
• Adjudicate commercial and Medicare Advantage claims.
• Identify and report processing inaccuracies related to system configuration.

Technical Qualifications

• 5 or more years of experience processing professional, ancillary, and institutional claims in Managed Care required.
• Deep understanding of CPT, ICD-9, ICD-10, HCPCS, Revenue Codes, medical terminology, and COB required.
• Comprehensive knowledge of DMHC and CMS guidelines for adjudicating commercial and Medicare Advantage claims.
• Comprehensive knowledge of fee schedules and CMS pricers, including Medicare DRG, APC, ASC, and SNF-RUG.
• Working knowledge of claims information systems.
• Typing speed of at least 45 words per minute.
• Able to prioritize, multitask, and manage claims assignments within regulatory and departmental requirements with minimal supervision.
• Can make phone calls to providers and billing offices as needed.
• Can interact positively and constructively with internal and external teams.

Timely indemnity payment processing, Benefit Notice issuance, and SROI transmission at a 99% timeliness goal depend on the Claims Examiner, who acts in a fiduciary role on behalf of insureds to assess payment need and coordinate return-to-work outcomes. Based within the claims department and collaborating with medical providers, injured workers, and the Return to Work Coordinator, this role strengthens operational accuracy and ensures reserve adequacy throughout each case.

Areas of Ownership

• Make indemnity payments to claimants, including lump sum and ongoing payments covering initial, final, and retroactive periods.
• Issue Benefit Notices as required for the start, change, and end of benefits.
• Issue Permanent Disability denials in certain circumstances and notify the assigned examiner.
• Transmit Second Report of Information (SROI) to the state as required.
• Gather and document information from medical providers on the disability status of claimants.
• Refer cases to the Return to Work Coordinator and follow up until an offer is made or a final decision not to accommodate is reached.
• Refer cases to management by flagging them for review as appropriate.
• Notify the examiner of cases with indemnity payments and the need for appropriate reserves.
• Coordinate and process void, stop pay, and reissue of indemnity payments.
• Enroll claimants in the EFT program upon acceptance.
• Attend Examiner Certification training as directed.
• Draft settlement documents and calculate wage statements upon certification as an Experienced Examiner.

Qualifications & Experience

• Bachelor's degree from an accredited college or university preferred.
• 2 or more years of related administrative office work experience.
• Knowledge of workers' compensation principles and policies preferred.
• Proficient in MS Office and general PC applications.
• Strong written and verbal communication skills with attention to detail and adherence to deadlines.
• Ability to work both independently and collaboratively with all levels of staff.

As the Claims Examiner, this role coordinates provider contract configuration, validates Medi-Cal pricing, and adjudicates non-institutional claims across Medicare, Medicaid, and commercial lines using ICD-10 and CPT billing code sets. The provider contracting and claims operations teams rely on this work to maintain data integrity through correction of system-generated errors, processing of exception reports, and communication of required system updates before final adjudication.

Operational Focus

• Review pended claims for billing errors and questionable billing practices, including duplicate billing and unbundling of services.
• Process non-institutional claim types across all lines of business, including Medicare, Medicaid, and commercial.
• Configure provider contracts, fee schedule updates, and related documents.
• Develop configuration testing and validate accuracy of data loaded.
• Coordinate research and resolution of debarred and sanctioned providers.
• Correct system-generated errors manually before final claims adjudication.
• Communicate required system updates to provider contracting and claims operations teams.
• Process claims based on provider contracts, applicable regulatory legislation, and claims processing guidelines.
• Analyze and validate Medi-Cal pricing.
• Adjust and adjudicate claims, reviewing services for accurate charges using current billing code sets including ICD-10 and CPT codes.
• Validate eligibility and other health insurance coverage on claims, including Medicare primary and California Children's Services.
• Process claim exception reports as assigned.

Skills & Qualifications

• 2 or more years of claims processing experience in the health insurance industry or a medical healthcare delivery system required.
• Knowledge of basic medical terminology required.
• Knowledge of ICD-10 and CPT codes and authorization guidelines.
• Proficient in MS Word and Excel and the ability to work with proprietary software applications.
• Typing speed of 70 or more WPM with 10-key knowledge desired.
• Strong organizational skills with the ability to multitask and manage time effectively.
• Ability to exercise good judgment and work independently as part of a team.
• Available to work unscheduled overtime or weekend hours as required.

Claims Examiner guides management of an assigned block of long-term disability cases with longer duration and evolving medical conditions by developing strategic case plans, determining eligibility through contractual and medical documentation review, and coordinating return-to-work outcomes with Vocational Rehabilitation Counselors. The work directly supports department leadership and internal clinical resources alongside external employers and treating providers, ensuring client performance guarantees are executed within standard processing timeframes.

Leadership Responsibilities

• Proactively manage an assigned block of claims by maintaining regular contact with customers and staying informed of each case's facts and functional status.
• Develop and document strategic case plans focused on the future direction of each claim from a holistic viewpoint.
• Determine customer eligibility by reviewing contractual language and medical documentation, interpreting information, and making decisions based on facts presented.
• Use the claim dashboard to manage claim inventory and determine which claims to prioritize for maximum impact.
• Discuss return to work opportunities with customers and employers and communicate using an action-oriented approach.
• Work directly with clients and Vocational Rehabilitation Counselors to facilitate full-time or modified duty return to work.
• Consult internal and external resources to identify discrepancies, close gaps, and clarify inconsistencies in claim information.
• Medically manage claims by networking with customers and physicians from initial medical requests through ongoing evaluation.
• Execute on all client performance guarantees.
• Respond to all communications within customer service protocols in a clear and timely manner.
• Make fair, accurate, and timely claim decisions.
• Adhere to standard timeframes for processing mail, tasks, and outliers.

Experience & Qualifications

• High school diploma or GED required; Bachelor's degree strongly preferred.
• Experience in hospital administration, medical office management, financial services, or business operations is an asset.
• Demonstrated experience with collaborative negotiations.
• Proficiency in MS Office applications, including Word, Outlook, and Excel.
• Technically proficient with the ability to navigate multiple applications simultaneously.
• Strong analytical and math skills.
• Strong critical thinking skills with the ability to work with a sense of urgency.
• Strong written and verbal communication, organizational, and time management skills.
• Proven ability to interact positively and effectively with challenging customers.
• Ability to give and receive feedback and adapt to change.

The Claims Examiner administers Workers' Compensation benefits to injured workers in accordance with statutory and case law, managing reserve creation, legal counsel direction, and subrogation pursuit within designated authority. Reporting to claims management and partnering with outside adjusters, medical specialists, vendor partners, and Claim Assistants, this role ensures claim data accuracy, cost containment compliance, and equitable resolution across an assigned caseload.

Strategic Responsibilities

• Investigate and gather necessary information to settle assigned claims.
• Communicate with insureds to obtain information necessary for processing claims.
• Direct and manage legal counsel to ensure timely and cost-effective litigation.
• Attend depositions and hearings as workload allows.
• Contact and interview claimants, doctors, medical specialists, or employers to obtain information needed to manage a claim.
• Examine claims investigated by outside adjusters and further investigate questionable claims to determine whether to authorize payments.
• Pursue subrogation, recoveries, and contributions within statutory timeframes.
• Present cases and participate in their discussion at claim committee meetings.
• Create and adjust reserves on time consistent with company policies.
• Manage and approve payment of benefits within designated authority level.
• Resolve claims fairly and equitably in the best interest of the insured while providing timely benefits to injured workers as required by law.
• Report overpayments, underpayments, and other irregularities.
• Ensure accuracy of data in the claims system for compliance with applicable regulatory reporting.
• Ensure appropriate referral to vendor partners to comply with cost containment procedures and reduce overall claim costs.

Minimum Qualifications

• High school diploma or GED required; Bachelor's degree from a four-year college or university preferred.
• State Workers' Compensation License required in applicable branches.
• Must receive certification meeting minimum standards of training, experience, and skill.
• WCCA and WCCP designations not required but preferred.
• 1 to 3 years of relevant work experience required.

Embedded within the auto liability and cargo claims function, the Claims Examiner manages claims up to $5,000 under routine supervision, conducting investigations, assessing negligence, and negotiating settlements with plaintiff attorneys and insurance companies within individual authority limits. Working closely with local law enforcement, on-scene adjusters, and department management, this role reduces financial loss and reputational risk by ensuring all claims are thoroughly examined and that fleet compliance with federal, state, and local regulations is maintained.

Work Activities

• Manage claims under auto liability, general liability, or cargo insurance coverage.
• Ensure the motor fleet is in compliance with federal, state, and local laws, regulations, and company policies.
• Follow established procedures and perform assigned tasks where instructions are detailed.
• Evaluate and manage the organization's exposure to risk up to $5,000, ensuring claims are thoroughly examined to minimize financial loss.
• Involve management when scope or exposure exceeds the defined authority range.
• Conduct initial and follow-up contact with claimants, insurance companies, and attorneys regarding claim submission.
• Assess liability to apportion damages based on percentage of negligence for negotiating settlements.
• Negotiate with plaintiff attorneys and insurance companies to settle vehicle and personal injury claims within individual authority limits.
• Maintain a suspense system to ensure regular review of case files.
• Monitor case files daily to determine whether reserves are set accurately and adjust within authority.
• Manage routine and emergencies involving vehicular accidents, drug and alcohol allegations, safety issues, workers' compensation claims, or cargo claims.
• Coordinate with local law enforcement and adjusters on-scene to gather information and control liability.
• Record and document vital information in the company's information systems.

Background & Experience

• High school diploma or GED with 0 to 1 year of combined education, experience, and training required.
• Associate's degree with 1 to 2 years of combined education, experience, and training preferred.
• Experience working in claims.
• Proficient active listening and time management skills.
• Ability to make independent, time-sensitive decisions.
• Ability to multitask and work both individually and as part of a team.
• Ability to maintain professionalism when dealing with difficult individuals.
• Self-motivated with a strong work ethic.