The Claims Examiner is a member of the department. This position is primarily responsible for the accurate and timely adjudication of claims.


1.     Adheres to and supports the mission, purpose, philosophy, objectives, policies, and procedures.
2.     Adheres to the HIPAA Compliance Plan and the Privacy Standards Confidentiality Agreement.
3.     Demonstrates support for the Corporate Compliance Program by being knowledgeable of compliance responsibilities as expressed in the Code of Conduct; adhering to federal and state laws, rules, regulations, and corporate policies and procedures policies that affect his/her specific job functions/responsibilities; and reporting compliance issues/concerns in a timely and appropriate manner.
4.     Understands all contracts  and ability to process the claims accurately and timely.
5.     Adjudicates claims in accordance with policy and successfully achieves the productivity standards set forth for this position.
6.     Communicates claims related information to customers through telephone contact and written communication.  Resolves and documents customer issues. Escalates more complex issues to the department leads.
7.     Listens and communicates effectively with customers (Health Plans, Providers).

Job Requirements


  • Education:  High School diploma or GED.
  • Experience:  Claims Examiner level I – 1-2 years prior experience
  • Knowledge, Skills & Abilities:  Solid oral and written communication skills; understanding of operative and consultation reports; knowledge of claims adjudication procedures; knowledge of CPT and ICD-9 codes, RBRVS/Medicare rate structure, HCPCS codes and ASA code and rate structure; ability to follow written and oral directions with minimal instruction; ability to problem solve in a timely manner; ability to calculate contracted rates; ability to prioritize and organize work area despite multi-faceted task directions and interruptions; knowledge of HMO contractual payment methodology.

2.   Certification/Licensure:  None required.
3.   TYPICAL PHYSICAL DEMANDS/WORKING CONDITIONS:  (see Working Conditions-Physical Demands form for CBO-MCO Billing Staff)

 *NOTE:  This job description is intended to be a representative summary of the major responsibilities and accountabilities of the incumbents holding this position. The incumbents may be requested to perform job-related tasks other than those stated in this description.