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Claims Examiner I

Job Category:  Claims
Department:  Claims Integrity

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  9682

Salary Range:  $50,216.00 (Min.) - $62,770.00 (Mid.) - $75,324.00 (Max.)


Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Claims Examiner is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes:
  * Processing claims for all lines of business, including complex claims
  * Monitoring itemized billings for excessive charges, duplications, unbundling, and medical coding
  * Determining prior authorization/precertification of services paid via system and/or health services
  * Requesting and reviewing medical records as needed for basic information to validate billing information
  * Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated.
  *Meeting and exceeding performance measurements for Claim Examiners as required by department to meet regulatory compliance.


Processing incoming claims: Determining correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions. Processing all claims eligible Or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner. Documenting provider claims/billing forms to support payments/decisions. Negotiate reimbursement amounts for out-of-network claims. Identifies dual coverage, Potential third party savings/recovery. Maintaining department databases used for report production and tracking on-going work. Claims will be processed within the contractual and/or regulatory time frames within or less than 45 working days and as supported by the departmental policies. (60%)

Perform special projects and ad-hoc reporting as necessary. Projects will be complete and reports will be generated within the specific time frame agreed upon at the time of assignment. (15%)


Assist management with in-house and on-site training as offered to employees, contracted partners and providers. (5%)


Working with internal departments to resolve issues preventing claims processing or enhancing processing capabilities. May assist in testing, changing, analyzing and reporting of specific enhancements. (5%)


Attend meetings as required. Claims Department/Operations Division will be represented at internal and external meetings. (5%)


Perform other duties as assigned. (10%)

Duties Continued

Education Required

High School Diploma/or High School Equivalency Certificate

Education Preferred


At least 0-1 years of healthcare claims processing experience in a managed care environment. 


Previous Medi-Cal claims processing experience, knowledge of State Department of Health Services regulations, and previous experience in EDI Claims processing a plus.


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


Strong communication skills with excellent analytical and problem-solving skills. 


Ability to self-manage in a fast-paced, detail-oriented environment. 


Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials (PDR, CPT, ICD-10, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge. 


Moderate knowledge of Microsoft Word and Excel.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements


Additional Information

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.  The range is subject to change.


L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)


Nearest Major Market: Los Angeles

Job Segment: Medical Coding, Claims, Healthcare, Insurance

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