Cedars-Sinai Claims Examiner 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. Processes claims according to all CMS and DMHC guidelines. Investigate and complete open or pended claims. Meet production and quality standards.

Essential Job Duties:

•Meets productivity standards for number claims completed and for accuracy of entries.

•Handles in a professional and confidential manner all correspondence.

•Supports CSMNS core values, policies, and procedures.

•Receives, and adjudicates medical claims for processing; reviews scanned, EDI, or manual documents for pertinent data on claim for complete and accurate information.

•Receives daily workflow via reports or work queue and incoming phone calls.

•Researches claims for appropriate support documents.

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

•Responds and documents resolution of inquiries from internal departments.

•Assists Finance with researching provider information to resolve outstanding or stale dated check issues.

•Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases.


High school diploma required.


Three (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). Ability to interpret Health Plans Division of Financial Responsibility for both IPA and Hospital Risk. Knowledge of medical terminology, CPT, HCPCS, Revenue Codes and ICD-10 codes. Working knowledge of coordination of benefits and Correct Coding Initiative edits. Knowledge and understanding of federal and state statutes, laws, rules and regulations. Flexible and detail oriented. Excellent verbal and written communication skills in the English language required.