Claims Examiner II

Claims Irvine, California


Job Description Summary

This position reports to the Supervisor, Claims in a production environment.  Claims Examiner II is responsible for reviewing, processing medical, dental, vision and electronic claims within the established turn-around time and department quality standards. Position may also process Flexible Spending Account (FSA), multiple surgery, Blue Card, foreign claims, Medicare Secondary Payer (MSP), coordination of benefit claims, and Health Insurance Payment Demand (HIPD) claims.


  • High school education or equivalent and minimum of two - three years of experience as a health claims examiner processor
  • Two years of experience with International Classification of Diseases (ICD) 9 and 10, coordination of benefits, Medicare, surgery claims, subrogation, and accident claims.
  • Proficient with medical coding and terminology.
  • Good verbal and written communication skills.
  • Proficient in ten key data entry.
  • Ability to work under pressure and adapt to changing environment.
  • Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines.
  • Proficient in Microsoft Office (Word, Excel, Outlook).
  • Reliability and a strong work ethic are a must.
  • Ability to work overtime as needed.

Duties And Responsibilities

Claims Processing

  • Examine Cedar claims, including pricing and processing within established specific guidelines
  • Examine and process professional, dental, vision claims including: physician claims, Medicaid reclamation, HIPD, FSA, Blue Card, foreign claims, other re-pricing claims, emergency room, outpatient lab and x-ray, accident and Third Party Liability (TPL) claims, Medicare Secondary Payer (MSP) and surgery claims.
  • Manual intervention, document information required to examine claims that are over $5,000.00.
  • Process claims adjustments, re-pricing and corrections.
  • Resolve benefit and eligibility issues that require detailed knowledge, support for customers and examination within the claims processing guidelines.
  • Resolve pended claims within ERISA guidelines.
  • Research and complete all correspondence related to all electronic and paper claims assigned.



Quality Results

  • Meet department standards for both production and quality.
  • Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation. Utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
  • Respond to internal/external customer inquiries and requests within the established timeframe.



  • Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.
  • Other duties as assigned.


Physical Demands/Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand, walk and sit. The employee is frequently required to use hands to finger, handle, or feel objects, tools, or controls and reach with hands and arms. The noise level in the work environment is usually moderate.