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Managed Care Claims Examiner
at agilon health
Anaheim, CA

Managed Care Claims Examiner
at agilon health
Anaheim, CA

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Job Description

Position Summary:

The Claims Examiner is responsible for processing, examining, and adjudicating medical claims for payment or denial in a manner that maintains compliance and within the Medicare and Medicaid regulatory requirements while achieving claims service level objectives. This position is responsible for the accurate and timely processing of all claims upon first receipt. Resolves claims payment issues as presented through the Provider Dispute Resolution (PDR) process or provider inquiries and identifies root causes of claims payment errors. The Claims Examiner responds to provider inquiries/calls related to claims payments and collaborates with other departments and/or providers to successfully resolve claims-related issues.

Essential Job Functions:

  • Follows established policies and procedures and use available resources such as provider contracts, Medicare and/or Medicaid guidelines and Member Evidence of Coverage (EOC) to process, and adjust routine assigned claims in an accurate and timely manner.
  • Adjudicates medical claims according to regulatory and company’s processing guidelines and contractual agreements.
  • Researches, identifies, resolves, and responds to inquiries from internal departments regarding outstanding claims-related issues and identifies root causes of claims issues/deficiencies.
  • Notifies Claims Management immediately when claims or other projects cannot be completed within the processing timelines.
  • Performs payment reviews and adjustments due to retroactive effective date of contracts and/or fee schedule changes.
  • Participates in system testing and communicates newly-identified and potential issues to the Claims Supervisor and/or Manager.
  • Attends and actively participates in daily, weekly, and monthly departmental meetings, training and coaching sessions.
  • Resolves claims payment issues as presented through Provider Dispute Resolution (PDR) process and/or provider calls.
  • Maintains productivity and quality standards as defined by Management.
  • Communicates with other departments to resolve provider claims related issues.
  • Contacts providers either telephonically or in writing for additional information to resolve or clarify submitted claims issues.
  • Handles misdirected claims inquiries.
  • Other related duties, as assigned                                                                                         

Other Job Functions:

  • Understand, adhere to, and implement the Company’s policies and procedures.
  • Provide excellent customer services skills, including consistently displaying awareness and sensitivity to the needs of internal and/or external clients.  Proactively ensuring that these needs are met or exceeded.
  • Take personal responsibility for personal growth including acquiring new skills, knowledge, and information.
  • Engage in excellent communication which includes listening attentively and speaking professionally.
  • Set and complete challenging goals.
  • Demonstrate attention to detail and accuracy in work product.

Required Qualifications:

Minimum Experience

  • 3 years Medicare and Medicaid claims processing experience
  • Knowledge of medical terminology, ICD-9/ICD-10, CPT and DRG coding, required.
  • A minimum of two years of experience in a managed care organization, preferred.
  • Excellent knowledge of claims systems.
  • Ability to demonstrate organizational, interpersonal, and communication skills.
  • Ability to maintain designated production and quality standards.
  • Knowledge of different providers’ payment methodologies (i.e., capitation, fee for service based on RBRVS, Medicaid and other negotiated flat rates, RVS pricing, Per Diem, DRG pricing, etc.), preferred.
  • Ability to deal with complex claim issues.
  • Knowledge of Medicare and Medicaid claims processing guidelines, Title 28 Claims Settlement Practices and other regulatory requirements.
  • Proficient with Microsoft Office programs including PowerPoint, Outlook, Word, Excel and common computer equipment and office hardware


  • High school or equivalent

Company Description

The passion to change the way healthcare is delivered permeates everyone and everything at agilon health. Working together we can use our expertise to make a difference in the lives of patients and physicians alike. We can bring the joy back to practicing medicine for physicians and improve the care experience for patients across the country.

We believe that every member of our team plays a critical role in transforming care for our patients. Our customer service teams are the front line for physicians and patients navigating the system and, without our claims processing departments, our health plan partners and provider networks couldn’t do their jobs. No matter what your role is at agilon health, you can and will make a difference in the lives of the seniors and Medicaid populations we serve. Our culture and passion has already been embraced by nearly 500 employees in three states. And we are excited to welcome new members to the team as more physicians and patients experience the difference agilon health can make.

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