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North East Medical Services · 1 month ago

CLAIMS EXAMINER II

Burlingame, CA

Full-time

Hybrid

Mid Level

$36/hr - $41/hr

3+ years exp

North East Medical Services is seeking a Claims Examiner II responsible for the daily review, audit, examination, investigation, and adjudication of hospital and professional claims. The role involves ensuring compliance with established guidelines and preparing documentation for health plan audits, while also providing assistance in training entry-level staff.

Hospital & Health Care

H1B Sponsor Likely

Responsibilities

Perform the daily examination, auditing and adjudication activities to submitted hospital and professional claims based on established utilization criteria, Medi-Cal and/or Medicare guidelines, member’s Evidence of Benefit, and policies and procedures outlined in the MSO Claims Manual

Responsible for the daily review of complex pre-payment claims reports. Identify processing errors and make corrections prior to the weekly FFS payment cycle

Identify claims payment errors and perform claims revision/correct activities for repayment or deduction per Physician and/or Vendor Contract terms

Must meet quantitative production standard of 750 claims per week

Provides feedback on testing system upgrades and enhancements

Respond to complex provider inquiries related to claims adjudication, denial, and payment status and handle member billed issues when arise

Respond to first level provider inquiries related to claims adjudication, denial, and payment status and handle member billed issues when arise (when necessary)

Responsible to prepare, review, and submit claims files and evidence documents for the annual delegation oversight audit(s) performed by Health Plan(s)

Provide recommendations to Claims Manager on updating claims policies and procedures to meet turn-around-time and/or CMS/DHCS/MCP regulatory requirement

Assist in training the entry level Claims Examiner for claims auditing and adjudication activities, and other MSO staff with general claims information

Identify system configuration errors and flaws during day-to-day operation, report to department supervisor, manager and MSO System Configuration team to correct/resolve them

Identify auditing errors and/or training-related opportunities that will improve operational efficiencies and results

Provides information in response to the requests of patient, physician, insurance company or co-worker as appropriate

Prepares and interprets appropriate statistical reports

Performs other job duties as required by manager/supervisor and NEMS Management Team

Qualification

Health insurance claims processingHealthcare compliance knowledgeMedical terminology knowledgeAnalytical skillsPC software proficiencyProblem solving skillsEnglish communication skillsOrganization skillsTime management skillsDetail oriented

Required

Completion of a 2-year degree from an accredited University, may be substituted with relevant work experience in healthcare medical claims processing and examination field

Minimum 3-4 years of experience in health insurance claims processing, examination, adjudication, and auditing

Strong knowledge of managed care and/or healthcare claim reimbursement or medical billing in Medi-Cal and Medicare Advantage program required

Working knowledge of State/Federal healthcare compliance requirements (HIPAA, AB1455, and ICE standards), particularly DHCS/Medi-Cal and CMS/Medicare guidelines required

Working knowledge of medical terminology, standard code sets including CPT, HCPCS, ICD, POS, and claim forms

Strong English communication skills with strong analytical and problem solving skills

Ability to self-manage in a detail oriented environment

Good organization and prioritization skills, outstanding in time management

Must be able to fluently speak, read and write English

Preferred

Ability to operate PC based software programs or automated database management systems preferred

Fluent in other languages are an asset

Benefits

Free medical, dental and vision insurance for employee, spouse and/or children

Company contribution to 401(k)

Company

North East Medical Services

North East Medical Services (NEMS) is one of the largest community health centers in the United States targeting the medically underserved Asian population.

Founded in 1968

San Francisco, CA, US

501-1000 employees

https://www.nems.org/

H1B Sponsorship

North East Medical Services has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (20)

2024 (7)

2023 (8)

2022 (5)

2021 (1)

2020 (1)