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Cedars-Sinai Claims Examiner - Managed Care in Encino, California

The Claims Examiner

is responsible for accurately and consistently adjudicating claims in

accordance with policies, procedures and guidelines as outlined by the company

policy. Process claims according to all CMS and DMHC guidelines. Investigate

and complete open or pended claims. Meet production and quality standards.

Essential JobDuties and Responsibilities:

  • Meetsefficiency standards for number claims completed and for accuracy ofentries.

  • Handles in aprofessional and confidential manner all correspondence.

  • SupportsCedars-Sinai Medical Network Services core values, policies, andprocedures.

  • Receives, andadjudicates medical claims for processing; reviews scanned, EDI, or manualdocuments for pertinent data on claim for complete and accurateinformation.

  • Acquires dailyworkflow via reports or work queue and incoming phone calls.

  • Researchesclaims for appropriate support documents.

  • Analyzes andadjusts data, determines appropriate codes, fees and ensures timely filingand contract rates are applied.

  • Responds anddocuments resolution of inquiries from internal departments.

  • AssistsFinance with researching provider information to resolve outstanding orstale dated check issues.

  • PerformsProvider Dispute Request (PDR) fulfillment process from the point of claimreview through letter processing and records outcome in applicabletracking databases.



school diploma or GED required.



(3) plus years of medical claims processing for Medicare and Commercial

products and provider dispute resolution processing in an IPA, HMO and hospital

related setting. Knowledge of general claims processing principles. Knowledge

of CMS and UB coding. Experience with processing all types of specialty claims

such as Chemotherapy, Dialysis, OB and drug and multiple surgery claims.

Experience on an automated claims processing system (Epic Tapestry preferred).

Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.