Claims Examiner III
Location: Pasadena, CA (Hybrid considered after training once performance expectations are consistently met)
Schedule: Monday – Friday, 8 am – 5 pm
Pay Rate: Up to $34.00 per hour, depending on experience
Employment Type: Temp to perm

Position Overview
A healthcare IPA is seeking an experienced Claims Examiner III with advanced, hands-on claims examination and adjudication experience.

Candidates must have direct experience independently reviewing, pricing, adjusting, and adjudicating complex professional and facility claims within a managed care, IPA, MSO, medical group, TPA, or health plan environment.

Required Experience With

Direct claims examination and adjudication
Professional claims — CMS-1500
Facility claims — UB-04
Provider contracts
Health plan contracts and benefits
CMS guidelines
Medicare and commercial claims
Medical policies and coding guidelines
CPT, HCPCS, ICD, and revenue codes
DRG and APC reimbursement methodologies
Complex, high-dollar, pended, and adjusted claims
Claims pricing, denials, and payment determinations

Key Responsibilities

Review, research, price, adjust, and adjudicate complex healthcare claims.
Determine whether claims should be paid, denied, pended, reduced, or adjusted.
Apply provider contracts, benefit guidelines, medical policies, coding rules, and regulatory requirements.
Process professional and facility claims accurately and within required timeframes.
Identify coding, billing, pricing, contractual, or system issues affecting claim payment.
Research and resolve claim discrepancies and exceptions.
Maintain required quality, productivity, and accuracy standards.
Follow HIPAA, CMS, compliance, and company claims-processing guidelines.

Qualifications

Several years of recent, direct healthcare claims examination and adjudication experience.
Prior Claims Examiner III, Senior Claims Examiner, Advanced Claims Processor, Claims Auditor, or similar experience preferred.
Strong knowledge of professional and facility claims.
Ability to independently handle complex claims with limited supervision.
Strong analytical, research, and problem-solving skills.
Dependable, accurate, and able to meet production standards.