The Lead Claims Examiner of the Production Unit is responsible for ensuring that all designated employees are provided their daily assignment of claims, ensuring compliance with timeliness of payment by assigning oldest dates first and by line of business. The Lead Claims Examiner will also serve as back up to the Claims Supervisor, when not onsite, by answering claims examiners questions. The Lead Claims Examiner will also assist by processing medical claims in an efficient, cost-effective, and timely manner. Responsible for meeting all required guidelines and performing adjustments as necessary, including special projects. In addition, they will serve as back up to the other Leads in the department when necessary and will report directly to the Claims Supervisor.

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

Required Skills

• Knowledge of claims regulatory timeframes/timeliness of payment.
• Full understanding of HMO & capitation concepts and Medicare guidelines;
• Extensive knowledge of facility, ancillary and professional claims
• Knowledge of medical terminology & RVS/CPT/RBRVS/ICD-10 codes.
• Experienced with provider contract payment methodologies including, but not limited to, case-rates and stop-loss.
• Excellent communication, problem solving, and decision-making skills coupled with the ability to work successfully in a team environment.

Required Experience

• Minimum three (3) years of experience in processing medical claims
• Knowledge of regulatory requirements (CMS, DMHC and DHS)
• Proficiency in Healthcare and Health Plan terminology, medical coding (e.g. CPT4, ICD9, and HCPCS), provider contracts and common claims adjudication practices.
• Strong analytical and problem solving skills.
• High School Diploma or General Education Development (GED) required.

• Knowledge of claims regulatory timeframes/timeliness of payment.
• Full understanding of HMO & capitation concepts and Medicare guidelines;
• Extensive knowledge of facility, ancillary and professional claims
• Knowledge of medical terminology & RVS/CPT/RBRVS/ICD-10 codes.
• Experienced with provider contract payment methodologies including, but not limited to, case-rates and stop-loss.
• Excellent communication, problem solving, and decision-making skills coupled with the ability to work successfully in a team environment.