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Providence Health & Services Claims Examiner I in Mission Hills, California


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Providence is calling a Claims Examiner I (Full time/Day Shift) to Providence Facey Medical Foundation in Mission Hills, CA.

Please upload a current resume reflecting all professional nursing experience.

We are seeking a Claims Examiner I who will review and process provider claims based on provider and health plan contractual agreement, claim processing and reimbursement guidelines, and company policies and procedures. Respond to and resolve provider and health plan claims inquiries and apply resolution in a timely fashion. Maintain departmental standards on productivity and quality of work.

In this position you will:

  • Perform job functions timely and efficiently

  • Deliver upon the service expectations of both our patients and fellow staff members by listening to their needs; engaging in positive interactions; and following through on promises made in a thoughtful, efficient, timely and courteous manner so that their total outcome is better than expected

  • Respect the dignity, confidentiality and privacy of patients

  • Work in a safe manner, adhering to general safety precautions and standards. Report any unsafe conditions to their supervisor and/or the safety hotline

  • Sort and prepare claims for data entry in the IDX System

  • Input claims into the system for appropriate tracking and processing

  • Analyze and process claims from providers based on provider contractual agreement, health plan division of financial responsibility, claims processing guidelines, and company policies and procedures

  • Analyze and process senior member claims based on CMS's timeliness and accuracy regulations

  • Analyze and process commercial member claims based on federally and non-Federally- qualified HMO turnaround time guidelines

  • Review services for appropriateness of charges and medical necessity and ensure that prior authorization and pre-certification guidelines are implemented

  • Pay claims based on contractual rates negotiated by Facey Medical Foundation Management. Calculate and apply usual, customary, and reasonable rates on non-contracted provider claims, implement Medicare rates on senior member claims from non-contracted and ancillary providers

  • Process and process claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e. co-payments, deductibles, etc.

  • Act as a resource and respond to and follow-up on claims inquiries from providers, provider billing offices and health plan representatives

  • Research and adjust claims when appropriate and return incomplete or incorrect claims to provider with follow up

  • Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines. (Minimum 120 claims per day, with no more than 2% error rate

  • Participate in special projects, complete tasks assigned by management in a timely manner

  • Identify third party liability claims and notifies supervisor

  • Must also meet productivity goals of processing a minimum 120 to 160 claims per day with no more than a 2% error rate

  • Interface effectively with HMOs

  • Insure timely response to inquires from HMO regarding payment of assigned claims

  • Follow HMO guidelines in the claims process


Required qualifications for this position include:

  • 2 years HMO claims processing experience required in a managed care environment

  • Knowledge of medical terminology and coding

  • Familiar with CMS and Dept. of Managed Health Care mandates

  • Ability to type 35 WPM

  • Use a ten key adding machine

  • Perform data entry and make mathematical calculations

  • Effective communication skills

Preferred qualifications for this position include:

  • PMG/IPA setting within the last three years or any combination of education and/or experience which produces an equivalency

About the organization you will serve:

Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita and Simi Valleys. The group began as a single medical practice over 90 years ago.

Facey is part of Providence Health & Services, an integrated, not-for-profit 5-state network of hospitals, care centers, medical clinics, affiliated services and educational facilities spanning from California to Alaska.

We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Day

Job Category: Customer Service

Location: California-Mission Hills

Req ID: 309197