The Claims Examiner is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes: Processing claims for all lines of business, including complex claims Monitoring itemized billings for excessive charges, duplications, unbundling, and medical coding Determining prior authorization/precertification of services paid via system and/or health services Requesting and reviewing medical records as needed for basic information to validate billing information Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system and updating and releasing pending claims when indicated Meeting and exceeding performance measurements for Claim Examiners as required by department to meet regulatory compliance Processing incoming claims Determining correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions Processing all claims eligible or ineligible for payment accurately and conforming to quality, production standards, and specifications in a timely manner Documenting provider claims / billing forms to support payments / decisions Negotiate reimbursement amounts for out-of-network claims Identifies dual coverage, potential third party savings / recovery Maintaining department databases used for report production and tracking on-going work This position is located in Los Angeles, California. The successful applicant will possess the following requirements (items are required unless noted otherwise): Minimum 3 years of experience with medical insurance claims (processing of claims) within hospital environments Minimum 2 years of experience with Medi-Cal / Medicare