Claims Examiner III - University Healthcare Alliance
  • 1376473025145
  • Claims Examiner III

    Affinity Medical Solutions
    Richmond, CA

    Position Details

    Affinity has an exciting opportunity for a Claims Examiner III. This position is responsible for independently reviewing, adjudicating and finalizing Provider Dispute Resolution (PDR) requests, processing claims adjustments requests received from Customer Service, and adjudicating special projects claims. Research and review necessary documentation and apply claims policy appropriately and accurately in order to resolve and finalize claims adjustment requests. Process professional and institutional electronic and paper medical claims. Meet established Claims department claims processing quality and production performance benchmarks. Effectively manage workload and prioritize assignments. Work without significant guidance. Ensures claims adjudication is in accordance with State, Federal and Health plan regulatory requirements as well as departmental guidelines.

    Desired Skills & Experience

    • Ability to work independently, organize, and prioritize work assignments
    • Independent decision making skills and demonstrate initiative to resolve issues
    • Excellent oral and written communication skills, great organizational skills and ability to prioritize projects
    • Ability to exercise good judgment and handle a fast paced environment
    • Able to assess and coordinate departmental work flows effectively 
    • Ability to process all types of medical claims and interpret authorizations, contracts and physician reimbursement methodologies   
    • High school graduate or GED
    • Knowledge of and working experience with ICD-9, CPT and HCPC coding systems
    • Thorough knowledge of medical terminology, enrollment and membership activities and claim processing procedures/systems
    • Basic understanding of Microsoft Word and Excel applications
    • Five (5) years prior claims processing experience in an IPA or HMO related setting
    • Prior experience with claims adjustments and PDR's preferred

    To Apply

    We invite you to send your resume and cover letter to Please include "Claims Examiner III" in the subject line.

    Equal Opportunity Employer