Senior claims examiner job description

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Hospital - Whittier, PIH Health Hospital - Downey and PIH Health Good Samaritan Hospital, 27 outpatient medical locations, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, women's health, urgent care and emergency services. The organization is recognized by Watson Health as one of the nation's Top Hospitals, and College of Healthcare Information Management Executives (CHIME) as one of the nation's top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. PIH Health is certified as a Great Place to Work
TM . For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.



The Senior Claims Examiner administers health plan contracts by processing medical claims in an efficient, cost-effective, and timely manner meeting all required guidelines and performs adjustments as necessary. Some of the duties include handling of Third Party Liability requests, Out-of-pocket Maximum requests, EDI rejects and other special projects.

Required Skills

Computer and 10-key skills by touch;
Knowledge of medical terminology, CPT/RBRVS/ICD-10 codes;
Full understanding of HMO & capitation concepts and Medicare guidelines;
Extensive knowledge of facility, ancillary and professional claims
Excellent communication skills
Ability to work independently and function under time deadlines.


Required Experience

Formal training will be indicated by a high school diploma or equivalent
Minimum two (2) years medical claims processing experience




Beyond the benefits that come with working for the area's leading community healthcare provider - one that also recognizes the need to ensure patient safety and comfort - you'll enjoy an extremely competitive compensation and benefits package. We are an equal opportunity employer and seek diversity in our workforce. EOE M/F/D/V

Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You'll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development.

Answers incoming phone calls on behalf of client; provides accurate and appropriate information to callers.
Your role in our mission

* Places outbound customer service or customer satisfaction calls, as required by client.
* Completes call guides; gathers and verifies required information.
* Attends telephone skills and program information training sessions; adheres to established levels of service.
* Adheres to established customer service and documentation standards within required time frames.
* Adheres to contact center scheduling, ensures telephone coverage during contact center hours of operation.
* Performs clerical or administrative duties as assigned.

What we're looking for

* No experience is required, but helpdesk, call center, or another customer service via telephone experience is helpful
* Experience working with fax machines, computer software, and telephone technology is a plus

What you should expect in this role

* Remote
* May require shift work

The pay range for this position is $30,500.00 - $43,500.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You'll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.

Looking for a company that is growing and innovative? Enjoy working autonomously and being rewarded for a job well done? Join Raphael and Associates as a Senior Property Claims Examiner, where you will manage the entire claims life cycle from inception to completion. You will be supported and surrounded by like-minded professionals whose focus is client satisfaction and exceeding expectations.

Here at Raphael and Associates we prioritize hiring top talent and ensuring a healthy work-life balance for our staff while focused on delivering exceptional services. You'll have the opportunity to work with skilled and experienced field adjusters and well-versed examiners. In addition, we provide opportunities for career advancement by supporting initiatives for continued education, certifications, and career development.
Responsibilities:

+ Oversee the investigation, reporting, inspection of losses, and computerized damage estimating of independent adjusters

+ Conduct thorough coverage analysis and create detailed reports for clients

+ Manage communications with insured

+ Work with internal departments including accounting and clerical staff

Key requirements:

+ At least 5+ years of commercial and residential property claims handling experience

+ Strong project management skills and ability to work independently

+ Excellent writing skills relating to policy interpretation

+ Strong customer service skills

+ Experience with claims handling systems

+ Experience evaluating property damage estimates (i.e. Xactimate)

+ State licensing a plus

Benefits and Perks:

We are an organization that recognizes and appreciates hard work! We offer a competitive compensation package commensurate with experience, including salary, bonus, paid time off, medical/dental/vision/life insurance, and 401k (with matching!). Most importantly, you will have the opportunity to work directly alongside an extraordinary and dedicated team to grow a critical function within a dynamic, growing company!

Company Overview:

Raphael & Associates is a third-party claims administrator and independent claims adjusting company internationally recognized for exceptional service. We understand the importance of adapting to the demands of a dynamic market and we tailor our services to our client's specific needs. As a claim's organization, what we do is complex. Our mission is simple: to provide outstanding service, retain extraordinary professionals, and utilize the best technology in the industry!

As a leading organization in the industry, we offer dynamic and challenging opportunities to individuals who want to make a difference. We value camaraderie, vision, a passion for excellence, creativity, and a "roll-up-your-sleeves, get it done" mentality. We are searching for experienced, energetic, creative, and self-reliant professionals for exciting career opportunities!

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