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 Whittier Hospital, PIH Health Downey Hospital 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 Lead Claims Examiner of the Production Unit is responsible for ensuring that all designated employees are provided their daily assignment of claims, ensuring compliance with timeliness of payment by assigning oldest dates first and by line of business. The Lead Claims Examiner will also serve as back up to the Claims Supervisor, when not onsite, by answering claims examiners questions. The Lead Claims Examiner will also assist by processing medical claims in an efficient, cost-effective, and timely manner. Responible for meeting all required guidelines and performing adjustments as necessary, including special projects. In addition, they will serve as back up to the other Leads in the department when necessary and will report directly to the Claims Supervisor.
The Lead serves as a role model within the department and throughout the organization.
Performs other duties as assigned by Management.
Knowledge of claims regulatory timeframes/timeliness of payment.
Full understanding of HMO & capitation concepts and Medicare guidelines;
Extensive knowledge of facility, ancillary and professional claims
Knowledge of medical terminology & RVS/CPT/RBRVS/ICD-10 codes.
Experienced with provider contract payment methodologies including, but not limited to, case-rates and stop-loss.
Excellent communication, problem solving, and decision-making skills coupled with the ability to work successfully in a team environment.
Minimum three (3) years of experience in processing medical claims
Knowledge of regulatory requirements (CMS, DMHC and DHS)
Proficiency in Healthcare and Health Plan terminology, medical coding (e.g. CPT4, ICD9, and HCPCS), provider contracts and common claims adjudication practices.
Strong analytical and problem solving skills.
High School Diploma or General Education Development (GED) required.
PIH Health is the Communities’ Health and Wellness Partner
Our network of highly trained and compassionate physicians, nurses, clinicians, staff and volunteers work tirelessly and collaboratively every day to maintain and enhance the health and wellbeing of every member of our service areas. And when needed, we are here to coordinate care, manage chronic disease, and treat health conditions for the best possible outcomes.
We’re a nonprofit, regional healthcare network with three hospitals, numerous outpatient medical offices, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. Our leadership is dedicated to putting patients first—a cornerstone of our mission, vision and values—as we deliver top-quality healthcare.
We serve more than 3.7 million residents in the Los Angeles County, Orange County and San Gabriel Valley region.
Why PIH Health?
Our culture is built around our core values, which are the guiding principles for everything we do. For over 60 years, PIH Health has maintained a sense of community and a family-like cultur...e where patients are the top priority, and employees and volunteers are proud to be affiliated with such an outstanding organization.
PIH Health Hospital - Whittier
Our Whittier campus delivers outstanding and compassionate care to patients, every day. Among other awards, PIH Health Hospital - Whittier has been named one of the nation’s 100 Top Hospitals® for the third consecutive year by Truven Health Analytics. PIH Health Hospital in Whittier, CA is located 30 minutes east of Los Angeles, close to the Los Angeles and Orange County border. There are many great communities in which to live that surround the hospital. This means easy access to work, great dining, shopping, entertainment and spectacular beaches. Whatever your passion, you’ll find the right place for it here.
PIH Health Hospital - Downey is a nonprofit hospital with a rich, nearly 100-year history of meeting the healthcare needs of its community. The Downey campus is part of the PIH Health comprehensive health network consisting of two hospitals, 18 medical office locations and a host of specialty services. According to US News & World Report, the hospital scores highly in patient safety and orthopedics. With 955 employees, the hospital is the 5th largest employer in the city of Downey.