Claims Examiner Specialist III

US-CA-Los Angeles
Job ID


Claims Examiner III is responsible for analyzing and adjudicating medical claims. Performs payment reconciliations and/or adjustments related to retroactive contract rate and fee schedule changes. Resolve claims payment issues as presented through Provider Dispute Resolution (PDR) process or from claims incident/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payments. Generates and develop reports which include but not limited to root causes of PDRs and Incidents. Collaborates with other departments and/or providers in successful resolution of claims related issues.



  1. Enter, process, analyze and research claims applying appropriate claim industry standards for all lines of business.
  2. Work and finalize aged and pended claims report daily.
  3. Meet or exceed minimum claims adjudication production/quality standards of processing 20 claims per hour with and accuracy rate of 95% or above.
  4. Execute and handle complex payment methodologies.
  5. Respond to and resolve provider and health plan inquiries.
  6. Responsible for provider/member dispute resolutions.
  7. Provide auditing of Claims Examiners I and II.
  8. Root cause system issues.
  9. Assist in creation of business rules and training to department staff.
  10. Provide back up to Compliance and Recovery Specialist.
  11. Other duties as assigned.


  1. High School graduate or equivalent.
  2. Minimum 5 years in managed care medical claims adjudication experience.
  3. Education and training and/or experience necessary to perform duties and position.


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