The claims examiner reports directly to the claims manager. They are primarily responsible for the processing functions (operation, adjudication, and payment) of UB-92 and HCFA-1500 claims that are received from PHP affiliated medical groups and hospitals for HMO patients. Requirements 2 YEARS EXPERIENCE REQUIRED - MUST BE ABLE TO VERIFY HS DIPLOMA or GED or HIGHER High school graduate or equivalent required. Must have physical proof on hand if background check is unable to verify your education background. Minimum of 2 years claims ADJUDICATION related experience in ambulatory, acute care hospital, HMO, or IPA environment. Knowledge of payment methodologies for: Professional (MD), Hospital, Skilled Nursing Facilities, and Ancillary Services. Knowledge and understanding of timeliness and payment accuracy guidelines for commercial, senior and Medi-Cal claims. Knowledge of compliance issues as they relate to claims processing. Ability to identify non-contracted providers for Letter of Agreement consideration. Training on basic office automation and managed care computer systems. #J-18808-Ljbffr