To review, research, and resolve claims for all Medi-Cal claim types within established
production and quality standards, including manual processing. Completes and processes claims
and claims worksheets. Creates appropriate documentation that reflects the actions taken and
status of the claim. Generates provider communication, such as letters, as necessary. Routes and
tracks claims requiring review by other staff and departments, and processes when possible.
Claims Examiner II is distinguished from Claims Examiner I by a higher level of autonomy and
experience, as well as an ability to process a wider range of claim types.

Essential Duties and Responsibilities

▪ Reviews, researches, and resolves pended claims for Medi-Cal types: medical, hospital,
ancillary, long term care, encounter data, other coverage, and batch claims within
established production and quality standards. Completes claims from the Batch Error
Report and Batch Pass Report.
▪ Routes claims to appropriate Partnership departments and internal staff for additional review.
Follows up and completes claims once response has been received.
▪ Follows established Partnership policies and procedures, Partnership Claims Operating Instruction
Memorandums, State of California Medi-Cal Provider Manual guidelines, Title 22
regulations, and CMS guidelines when resolving pended claims.
▪ Generates claims correspondence as needed.
▪ Records daily production statistics and related activities on appropriate reports. Turns in
all logs and reports to the Medi-Cal Claims Supervisor.
▪ Reviews all work audits in a timely manner and submits any adjustments and corrections
within the allotted time frame.
▪ Supports Claims Department’s needs for resolving all pended claim types.
▪ Participates in special projects and assignments as required.
▪ Identifies and reports trends of pending claims that are increasing or processes that
appear dated.
▪ Recognizes and gives feedback to management on procedure changes that would result in
more efficient operations.
▪ Other duties as assigned.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$ 31.4512- $ 37.74

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.