Claims Examiner III

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Imperial Management Administrators Services

Is responsible for adjudicating complex claims which include high dollar claims. Responsible for accurate manual/auto pricing of claims. Identify provider billing issues that impact claims processing. Works closely with the Supervisor to identify any reporting or training needs and system problems that may be encountered. Maintains quality and production standards, teamwork and comply with company/administrative policies and guidelines.


1.    Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e. co-payment, deductible, etc.


Review and process facility (UB-04) and professional claims (CMS-1500).
3.    Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups’ and company policies and procedures.


Process Medicare member claims based on DMHC and DHS regulatory legislature.
Respond to and resolve provider and health plan claims inquiries and give resolution in a timely manner.
Review services for appropriateness of charges and apply authorization guidelines during claims processing.
Monitor and track age, pended, and open reports to maintain timeliness in claims processing based on individual work allocation report.
Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines.
Ensures compliance with all applicable Federal, State and/or County laws and regulations related to our documented guidelines and processes.


·         High school graduate or equivalent.

·         Associate degree (A. A.) or equivalent from two-year college or technical school; some college courses, or six months to one-year related experience and/or training; or equivalent combination of education and experience

·         Must have at least 4 years of applicable healthcare claims adjudication experience within the managed care industry

·         Experience with ICD-9, HCPCS, CPT coding, APC, ASC and DRG pricing, CMS, DMHC regulations, facility and professional claim billing practices required

·         Multi-product line claims adjustment experience, preferred



Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and Ezcap Claims adjudication software, preferred

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