Medical Claims Examiner PPO Exp.

Medical Claims Examiner - PPO Claims Pasadena, CA $28.00 - $35.00 per hour Job Summary: We are seeking a detail-oriented and experienced Medical Claims Examiner to process and evaluate PPO claims for accuracy, completeness, and compliance with healthcare policies and procedures. The ideal candidate will have a strong background in healthcare claims processing, knowledge of medical terminology and insurance procedures, and familiarity with PPO networks. This role is essential in ensuring that claims are processed accurately and efficiently while adhering to regulatory standards and company policies. Responsibilities: Review, investigate, and process PPO medical claims to ensure accuracy, completeness, and compliance with company guidelines and regulations. Analyze claims data to confirm eligibility, coverage, and adherence to policy and procedural guidelines. Verify the accuracy of diagnosis codes, treatment procedures, and medical records to ensure proper claim adjudication. Communicate with healthcare providers, policyholders, and other stakeholders to obtain necessary documentation and clarify claim details. Identify and address potential issues, discrepancies, or fraud in claims and refer cases as needed for further investigation. Collaborate with team members and other departments to streamline claims processes and ensure timely resolutions. Maintain up-to-date knowledge of healthcare policies, procedures, and PPO network requirements to ensure compliance. Document all claim activities accurately in the system, maintaining detailed records and ensuring adherence to HIPAA regulations and company standards. Requirements: High school diploma or equivalent; bachelor's degree in healthcare administration, business, or related field preferred. Minimum of 2-3 years of experience in medical claims processing, preferably within a PPO environment. Strong understanding of healthcare insurance processes, medical billing codes (CPT, ICD-10, and HCPCS), and PPO claims handling. Excellent analytical and problem-solving skills, with keen attention to detail. Proficient in relevant claims processing software and MS Office applications. Exceptional communication and customer service skills. Ability to work independently as well as part of a team in a fast-paced environment. Knowledge of HIPAA regulations and compliance standards. Benefits: Competitive salary and benefits package. Opportunities for career advancement and professional development. A collaborative and supportive work environment. If interested send resume to: Call Carolyn direct (626) 389-1518 Desired Skills and Experience Medical Claims Examiner - PPO Claims Pasadena, CA $28.00 - $35.00 per hour Job Summary: We are seeking a detail-oriented and experienced Medical Claims Examiner to process and evaluate PPO claims for accuracy, completeness, and compliance with healthcare policies and procedures. The ideal candidate will have a strong background in healthcare claims processing, knowledge of medical terminology and insurance procedures, and familiarity with PPO networks. This role is essential in ensuring that claims are processed accurately and efficiently while adhering to regulatory standards and company policies. Responsibilities: Review, investigate, and process PPO medical claims to ensure accuracy, completeness, and compliance with company guidelines and regulations. Analyze claims data to confirm eligibility, coverage, and adherence to policy and procedural guidelines. Verify the accuracy of diagnosis codes, treatment procedures, and medical records to ensure proper claim adjudication. Communicate with healthcare providers, policyholders, and other stakeholders to obtain necessary documentation and clarify claim details. Identify and address potential issues, discrepancies, or fraud in claims and refer cases as needed for further investigation. Collaborate with team members and other departments to streamline claims processes and ensure timely resolutions. Maintain up-to-date knowledge of healthcare policies, procedures, and PPO network requirements to ensure compliance. Document all claim activities accurately in the system, maintaining detailed records and ensuring adherence to HIPAA regulations and company standards. Requirements: High school diploma or equivalent; bachelor's degree in healthcare administration, business, or related field preferred. Minimum of 2-3 years of experience in medical claims processing, preferably within a PPO environment. Strong understanding of healthcare insurance processes, medical billing codes (CPT, ICD-10, and HCPCS), and PPO claims handling. Excellent analytical and problem-solving skills, with keen attention to detail. Proficient in relevant claims processing software and MS Office applications. Exceptional communication and customer service skills. Ability to work independently as well as part of a team in a fast-paced environment. Knowledge of HIPAA regulations and compliance standards. Benefits: Competitive salary and benefits package. Opportunities for career advancement and professional development. A collaborative and supportive work environment. If interested send resume to: cdriedgerultimatestaffing.com Call Carolyn direct (626) 389-1518 All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance. For unincorporated Los Angeles county , to the extent our customers require a background check for certain positions, the Company faces a significant risk to its business operations and business reputation unless a review of criminal history is conducted for those specific job positions.