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Claims Examiner

Company: Innovative Management Systems Incorporated
Location: Whittier
Posted on: January 25, 2023

Job Description:


The Position.

We are looking for a detail-oriented individual that can accurately review, research, and analyze professional claims to determine and calculate the type and level of benefits based on established criteria and provider contracts. Experience in adjudication of Commercial, Medicare Advantage, and Medi-Cal claims will make you a great candidate, along with experience or familiarity with Healthcare Service industry, Independent Physician Associates (IPAs), and/or have experience in a Managed Care/Service Organization (MSO) or Health Plan background.

Some duties include:
Identifying authorizations and matching authorization to claims.
Troubleshooting and/or answering claims questions to internal/external stakeholders.
Adjudicating claims in the correct financial banks.
Identifying dual coverage and potential third-party liability claims.
Coordination of Benefits to management for approval and updating system insurance coverage profile.
Understanding and interpreting health plan Division of Financial Responsibilities and contract verbiage.
Supporting the Claims Departments and other Examiners and troubleshoots Claims issues for internal/external stakeholders.
Documenting resolution of claims to support claim payment and/or decisions.

The Specs.
Benefits Eligible: Medical, Dental, Vision, Paid Time off, and more.
Monday - Friday.
Work-Life Balance.

The Company.

Our team at IMS is looking for highly motivated individuals to join our growing start-up. We strive to innovate the healthcare industry by providing management and consultant services to Independent Physicians Associations (IPAs) and Health Plans. Our team utilizes their comprehensive knowledge of the healthcare industry to provide quality services for our contracted Medicare members in a fast-paced and multi-faceted environment. Our positions offer an in-depth perspective of the managed care industry to interested candidates that are looking to take risks and share in professional development and growth alongside our expanding company. If you are looking to make an impact in your career, in a flourishing new company, and in the healthcare industry, we welcome you to apply to join our team!

Innovative Management Systems is an equal opportunity employer. We celebrate teamwork, diversity, and inclusivity by creating a work environment where everyone respects each other, regardless of race, color, religion, sex, gender identity, sexual orientation, pregnancy, age, national origin, physical or mental disability, military or veteran status, genetic information, or any other protected classification.


What You Need.
High School Diploma and/or equivalent work experience in managed care/services, health plan, and/or IPA.
Minimum of 1 year of related claims processing experience in managed care/services, health plan, and/or IPA (preferred).
Knowledge of HCFA 1500 forms, CPT, and ICD codes (required).
Strong understanding of division of financial responsibility for determination of financial risk.
Practical knowledge and understanding of relevant business practices and applicable regulations/policies.
Excellent written and verbal communication.
Strong contract verbiage and knowledge of claims processing software.
Able to sit for long periods of time.
Professional behavior, good business judgement and strong team interaction skills.
Valid Driver's License or able to reliably commute to the office.
U.S. Work Authorization (required.)


Keywords: Innovative Management Systems Incorporated, Whittier , Claims Examiner, Other , Whittier, California

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