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Claims Examiner III

Job Category:  Claims
Department:  Claims Integrity

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  9327

Salary Range:  $60,778.00 (Min.) - $75,950.00 (Mid.) - $91,166.00 (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.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary

The Claims Examiner III is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes:

*Processing Medi-Cal CMS-1500 Professional and Ancillary. 
*Processing all Outpatient, Inpatient (High Dollar and Stoploss), SNF/LTC, Hospice, Home health, DME, Specialty, Dialysis and Injectable claims (UB-04 and CMS-1500) 
*Processing both Primary and Secondary claims (All LOB’s) 
*Identify duplications, unbundling, and knowledge of medical coding and terminology
*Validating prior authorization/precertification of services to process claim.
*Requesting and reviewing medical records as needed for basic information to validate billing information.
*Reviewing claims for required information, pending claims when necessary, and monitoring pend inventory to meet compliance requirements.
*Meeting and exceeding performance measurements for Claim Examiners as required by department to meet regulatory compliance.

Acts as a  Subject Matter Expert, serves as a resource and mentor for other staff.


Determining correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions. Identify dual coverage, potential third party savings/recovery, and process claims accordingly. Ensure Claims will be processed within the contractual and/or regulatory time frames as supported by the departmental policies. As a Subject Matter Expert, developing and conducting training on unit processes, for lower-tiered positions.  (60%)

Assist with special projects within Claims, responsible for working exception reports, and any other assigned reports. Complete User Acceptance Testing (UAT), changing, analyzing and reporting of specific enhancements and workflow configuration changes with Configuration Team. (30%)

Evaluate information against a set of standards and organize information in a clear and concise manner. Complete projects and reports within a reasonable timeline and by the appropriate deadlines. (5%)

Perform other duties as assigned. (10%)

Duties Continued

Education Required

Associate's Degree
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Bachelor's Degree


At least 6months-2 years of healthcare claims processing experience in a managed care environment.

Experience in handling complicated claims cases.

At least 6+ years Medi-Cal /Medicare claims.

Previous Medi-Cal claims processing experience and knowledge of State Regulations.


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-9, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge.

Moderate knowledge of Microsoft Word and Excel.

Department of Health Services regulations.

Knowledge of Medi-Cal and Medicare claims processing.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

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)


At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, it's expected that all employees wear a mask in areas where physical distancing cannot be managed.

Nearest Major Market: Los Angeles

Job Segment: Medical Coding, Medicare, Claims, Clinic, Hospice, Healthcare, Insurance

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